Bone Grafts and Bone Graft Substitutes in Periodontal ...76 2 Bone Grafts and Bone Graft Substitutes...

73A.L. Dumitrescu, Chemicals in Surgical Periodontal Therapy, DOI: 10.1007/978-3-642-18225-9_2, © Springer-Verlag Berlin Heidelberg 2011

Bone replacement grafts are widely used to pro-mote bone formation and periodontal regeneration. Conventional surgical approaches, such as open flap debridement, provide critical access to evaluate and detoxify root surfaces as well as establish improved periodontal form and architecture; however, these sur-gical techniques offer only limited potential in restor-ing or reconstituting component periodontal tissues (Fig. 2.1). Bone grafting materials function, in part, as structural scaffolds and matrices for attachment and proliferation of anchorage-dependent osteoblasts. Multiple classification systems have been used to organize bone replacement grafts, which commonly include source (e.g., allograft), chemical composition (e.g., calcium phosphate) and physical properties (e.g., ceramic). Advances in material sciences, however, have increasingly blurred such boundaries between types of bone replacement grafts (Reynolds et al. 2010).

Bone replacement grafts (bone grafts and bone graft substitutes) provide a structural framework for clot development, maturation and remodeling that supports bone formation in osseous defects. Bone grafting mate-rials also exhibit a variable capacity to promote the coor-dinated formation of bone, cementum and periodontal ligament (PDL) when placed and retained in periodon-tal defects. Bone grafting materials must possess the attributes of biocompatibility (lacking an immunogenic response) and osteoconductivity (providing a structure and surface topography that permit cellular attachment, proliferation and migration). Bone replacement grafts may also possess other properties that support osteogen-esis (Reynolds et al. 2010). Ideal characteristics of a bone graft are: nontoxic, nonantigenic, resistant to infection, no root resorption or ankylosis, strong and resilient, eas-ily adaptable, ready and sufficiently available, minimal

surgical procedure, stimulate new attachment and be able to trigger osteogenesis, cementogenesis and for-mation of a functional periodontal ligament (Rosenberg and Rose 1998; Nasr et al. 1999).

Osteogenic grafting materials, such as cancellous bone/bone marrow, contain living cells that are capable of differentiation and formation of bone. Osteoinductive grafting materials, such as demineralized bone matrix (DBM), provide a biologic stimulus (proteins and growth factors) that induces the progression of mesen-chymal stem cells and other osteoprogenitor cells toward the osteoblast lineage (Reynolds et al. 2010). Osteoinduction is a process or a set of processes that stimulate the phenotypic conversion of progenitor cells within the healing wound to those that can form osseous tissue (Nasr et al. 1999). Most bone replace-ment grafts are osteoconductive, relatively inert filling materials and integrate with new bone. Osteoconduction defines the process that permits osteogenesis when cells already committed to bone formation are present in a closed environment (Nasr et al. 1999).

In general, bone replacement grafts can be catego-rized into autogenous, allograft, alloplast and xeno-graft sources.

2.1 Autogenous Grafts

Autogenous bone graft, which is harvested from the patient’s own body, is considered ideal because of its osteoconductive and osteoinductive properties and because it contains a source of osteoprogenitor cells. It is still considered the gold standard by which other grafting materials are compared (Rosenberg and Rose 1998).

Bone Grafts and Bone Graft Substitutes in Periodontal Therapy

2

74 2 Bone Grafts and Bone Graft Substitutes in Periodontal Therapy

Gum

Bone

Blood clot

a

b

Membrane

c

Bone grafts

Fig. 2.1 Schematic diagrams of several techniques commonly used in periodon-tal surgery. (a) Open flap debridement (OFD) procedure involves the periodontal surgeon lifts the gum away from the tooth and surrounding bone, providing increased access for scaling and root planing. However, periodontal defects, if left empty after OFD, fill with the first cells to reach the area, that is, epithelial cells (1) and fibroblasts (2), after cell proliferation, which generates a core of fibro-epithelial tissues that attach to the root surface, hence bone (3) and periodontal ligament (4) regeneration are cumbered. (b) Guided tissue regenera-tion (GTR) is a surgical procedure that utilizes a barrier membrane which is placed under the gum and over the remaining bone to prevent epithelial down-growth (1) and fibroblast transgrowth (2) into the wound space, thereby maintaining a space for true periodontal tissue regenera-tion (3 and 4). (c) The use of bone grafts is a surgical procedure that replaces missing bone with material from the patient’s own body (autogenous bone) or an artificial, synthetic or natural substitute. Bone growth may be stimulated by the grafts and new bone fills the defect which may provide support for the tooth (Chen et al. 2010) (Reprinted with permission from Elsevier)

2.1.1 Intraoral Autografts

Intraoral autogenous bone grafts harvested from the maxillary tuberosity, edentulous alveolar areas, heal-ing bony wound, extraction sites and mental and retro-molar areas (Nasr et al. 1999, Rosenberg and Rose 1998) (Fig. 2.2).

Several types of autogenous bone grafts can be used (Rosenberg and Rose 1998; Mellonig 1992):

(a) Cortical bone chips – These are not used today because they are generally much longer particles 1,559.6 × 183 mm and have a higher potential for sequestration (Zaner and Yukna 1984).

752.1 Autogenous Grafts

(b) Osseous coagulum – This is made by harvesting intraoral bone with round burns, and then mixing it with blood (Robinson 1969; Jacobs and Rosenberg 1984). Early studies in monkeys showed that small particle size (100 mm) led to earlier and higher osteogenic activity than did the larger particles (Rivault et al. 1971). The disadvantages in using the osseous coagulum are the patient’s inability to aspirate during the collecting process, the unknown quality of the collected bone fragments, and the material’s fluidity (Diem et al. 1972).

(c) Blend of cortical and cancellous intraoral bone – Bone blend is the combination of cortical and can-cellous bone that is procured with a trephine or rongeurs, placed in an amalgam capsule, and tritu-rated to the consistency of a slushy osseous mass. The final particle size is about 210 × 105 mm (Zaner and Yukna 1984).

A technique based on the use of bone collectors for obtaining autogenous bone material, which allowed us to fill small bone defects, such as fenestrations and dehiscences, without having to involve a second (intraoral or extraoral) surgical area for obtaining autog-enous bone was recently presented Blay et al. (2003).

Bone collected through bone filters appears to be sufficient for small regenerative procedures. Clinicians should bear in mind that the presence of bacterial patho-gens is always shown with the use of bone collectors (Graziani et al. 2007). The stringent aspiration protocol, preoperative oral chlorhexidine rinse and antibiotic pro-phylaxis are important precautions to be implemented if collected bone articles will be implanted. With the

use of these methods, however, the risk of infectious complications remains. Therefore, decontamination pro-cesses are thought to only reduce microbial contamina-tion (Tezulas and Dilek 2008). In order to overcome some of these problems, a newly developed piezoelec-tric device (Piezosurgery) has been recently introduced for different bone augmentation procedures. The main advantages of the piezoelectric device may be because of its modulated ultrasound microvibrations (29 kHz, ranging from 60 to 200 Hz) which should prevent damages to the adjacent soft tissues during osteotomy procedures. However, both the harvesting methods, piezoelectric device or conventional rotating drills, are not different from each other concerning their detri-mental effect on viability and differentiation of cells growing out of autogenous bone chips derived from intraoral cortical sites (Chiriac et al. 2005).

2.1.2 Extraoral Autografts

Extraoral autografts from iliac cancellous bone and marrow provide a great osteogenic potential, being able to induce cementogenesis, bone regeneration and Sharpey’s fibers reattachment (Rosen et al. 2000).

Among the biomaterials, autogenous bone has been adopted as the gold standard because: (1) autograft bone includes cells participating in osteogenesis, (2) a tissue reaction is induced without inducing immuno-logical reactions, (3) there is a minimal inflammatory reaction, (4) there is rapid revascularization around the graft particles and (5) a potential release of growth and differentiation factors sequestered within the grafts (Marx 1994; Kim et al. 2005). Histological studies show that intraoral autografts are able to form new connective tissue attachment when implanted in intra-bony defects (Froum et al. 1983). In baboons, Cochran et al. (2003) showed that the combination of enamel matrix derivative and autogenous bone represents a therapeutic combination that can be highly effective in stimulating significant amounts of periodontal regen-eration (Fig. 2.3).

In perspective, autograft bone has been considered to yield a high osteogenic potential and has thus been used with the intent to improve outcomes of periodontal regenerative procedures (Dragoo and Sullivan 1973a; Froum et al. 1975a, 1975b, 1976; Hiatt and Schallhorn 1973; Ogawa et al. 1985; Renvert et al. 1985a;

Fig. 2.2 The collected bone particles were carried by sterile periost elevator (Tezulas et al. 2009) (Reprinted with permission from Elsevier)


Fig. 2.3 Periodontal healing in one-wall intrabony defects in dogs following implanta-tion of autogenous bone. (a) Photomicrograph of site receiving autologous bone showing new bone (NB) and cementum (NC) formation in the notch area (N) (H–E, original magnification ×20). The higher magnifications show the oblique or perpendicular collagen fiber arrangement. (b) A thick layer of new cementum with an oblique or perpendicular collagen fiber arrangement was observed in the notch area (H–E, original magnifi-cation ×100). (c) A well-organized periodontal ligament exhibiting a thinner new cementum layer was observed more coronally (H–E, original magnification ×200). (d) Newly formed bone trabeculae were lined with osteoblast-like cells (arrowhead) and exhibited perpendicularly oriented fibers (arrows) (H–E, original magnification ×400) (Kim et al. 2005) (Reprinted with permission from John Wiley & Sons)

Kim et al. 2005) (Fig. 2.4). Combined therapies using autogenous bone grafts with guided tissue regeneration (GTR) (Orsini et al. 2001, 2008; Camelo et al. 2001; Nygaard-Østby et al. 2008, 2010; Lindfors et al. 2010), Emdogain (Leung and Jin 2003; Trombelli et al. 2006; Guida et al. 2007; Yilmaz et al. 2010), platelet-rich plasma (Czuryszkiewicz-Cyrana and Banach 2006) and

autogenous periodontal ligament graft (Shirmohammadi et al. 2009) in the treatment of intrabony, furcation defects or peri-implantitis have been investigated.

In the review performed by Trombelli et al. (2002), only one parallel-arm trial (Movin and Borring-Møller 1982) comparing autogenous bone grafts to open flap debridement procedure was selected. The results

772.2 Allografts

Fig. 2.4 Case from autogenous bone graft group: (a) clinical appearance of the intrabony defect at tooth 23 at the time of surgery, (b) appearance of the defect, (c) placement of the autog-

enous bone graft, (d) suturing, (e) clinical appearance at 6 months posttreatment and (f) reentry (Shirmohammadi et al. 2009) (Reprinted with permission from Springer)

indicated a greater clinical attachment level (CAL) gain for grafted group (CAL gain: 3.2 mm, SD 0.5) compared with controls (CAL gain: 2.0 mm, SD 0.8). The difference in CAL gain between groups (1.20 mm, SE 0.39) was not statistically significant. In the system-atic review by Reynolds et al. (2003), two studies were included: Froum et al. (1976) and Renvert et al. (1985b). Autogenous bone treatment resulted in significantly greater clinical attachment level gain (weighted mean difference: 0.72 mm, SD 1.82) and bone fill (weighted mean difference: 1.62 mm, SD 1.53) for autogenous bone compared to open flap debridement (Table 2.1).

Although autograft procedures fulfill many of the characteristics of an ideal bone graft material, autografts are more invasive due to the additional surgical manipulations required to obtain donor tis-sue, and are limited by the relatively small quantity of bone that can be obtained from such techniques. These procedures also have been associated with postoperative root resorption. As a result, autografts may not be routinely practical in severe periodonti-tis cases involving multiple teeth and severe defects (Cohen et al. 1994). Root resorption and ankylosis in human after the transplantation of fresh iliac mar-row and cancellous bone has been reported (Dragoo and Sullivan 1973b; Schallhorn and Hiatt 1972).

2.2 Allografts

The allografts are obtained from other individuals of the same species but disparate genotype. They include freeze-dried bone allografts (FDBA) and demineral-ized freeze-dried bone allograft (DFDBA). Bone allograft is the most frequently used alternative to autogenous bone for bone grafting procedures in the USA (Reynolds et al. 2010).

The two types of allografts work by different mech-anisms. FDBA provides an osteoconductive scaffold and elicits resorption when implanted in mesenchymal tissues. DFDBA also provides an osteoconductive sur-face. In addition, it provides a source of osteoinductive factors. Therefore, it elicits mesenchymal cell migra-tion, attachment and osteogenesis when implanted in well-vascularized bone, and it induces endochondral bone formation when implanted in tissues that would otherwise not form bone (Committee on Research, Science and Therapy of the American Academy of Periodontology 2001).

Under FDA regulations, facilities engaged in pro-curing and processing human tissues for transplanta-tion must ensure that specified minimum medical screening and infectious disease testing have been per-formed, and that records exist and are maintained to


Reconstructive procedure

Systematic reviews

Outcome No. of studies

Weighted mean difference (mm)

95% CI (SD) [SE]

P-value for difference

P-value for heterogeneity

GTR Murphy and Gunsolley (2003)

CAL change 18 1.15 N⁄A <0.0001 N⁄A

PD change 15 1.04 N⁄A <0.0001 <0.01

Needleman et al. (2001)

CAL change 10 1.11 0.63, 1.59 * <0.001

PD change 5 0.80 0.14, 1.46 * 0.04

Bone gain at re-entry

3 1.39 1.08, 1.71 * 0.65

GTR + bone substitutes

Needleman et al. (2001)

CAL change 2 1.25 0.89, 1.61 * 0.91

PD change 2 1.24 0.89, 1.59 * 0.85

Bone gain at reentry

1 3.37 3.14, 3.61 * –

Autogenous bone graft

Trombelli et al. (2002)

CAL change 1 1.20 [0.39] >0.20 –

Reynolds et al. (2003)

CAL change 3 0.72 (1.82) 0.030 NS

PD change 1 0.60 (1.35) 0.062 –

Bone fill 2 1.62 (1.53) 0.058 £0.004

Bone allograft Trombelli et al. (2002)

CAL change 6 0.36 −0.16, 0.87 0.174 0.013

PD change 6 0.41 0.16, 0.66 0.001 0.067


CAL change 11 0.44 (2.25) 0.008 NS

PD change 9 0.43 (2.25) 0.032 NS

Bone fill 12 1.06 (1.97) <0.0001 NS

Dentinallograft Trombelli et al. (2002)

CAL change 1 0.80 [0.38] >0.50 –

Coralline calcium carbonate


CAL change 4 0.90 0.53, 1.27 <0.001 0.104

PD change 4 0.04 −1.78, 1.87 0.962 <0.001


CAL change 4 0.91 (1.94) 0.004 NS

PD change 4 0.09 (2.16) 0.886 NS

Bone fill 3 2.21 (1.82) <0.0001 NS

Bioactive glass Trombelli et al. (2002)

CAL change 4 1.04 0.31, 1.76 0.005 0.024

PD change 4 0.60 0.20, 1.00 0.003 0.684


CAL change 4 1.05 (1.89) 0.022 NS

PD change 4 0.71 (2.22) 0.018 NS

Bone fill 4 1.61 (1.47) 0.086 0.006

Table 2.1 Mean differences (in mm) in clinical outcomes between reconstructive procedure and control (open flap debridement) procedures as assessed in systematic reviews

792.2 Allografts

document screening and testing for each human tissue. The American Association of Tissue Banks also sets standards, inspects facilities and accredits tissue banks in North America (Reynolds et al. 2010).

Both FDBA and DFDBA materials are widely used in periodontal therapy and there are no reports of disease transmission during the 30-year history of using freeze-dried bone allografts. Most bone banks adhere to the guidelines of the American Association of Tissue Banks (AATB) with respect to procurement, processing and sterilization of bone grafts (Centers for Disease Control and Prevention 2010). The AATB advocates excluding collection of bone under the following circumstances:

1. Donors from high-risk groups, as determined by medical testing and behavioral risk assessments

2. Donors test positive for HIV antibody by ELISA3. Autopsy of donor reveals occult disease

4. Donor bone tests positive for bacterial contamination5. Donor and bone test positive for hepatitis B surface

antigen (HBsAG) or hepatitis C virus (HCV)6. Donor tests positive for syphilis

The net result of human bone allograft processing is an exponential reduction in the potential for graft con-tamination, disease transfer or both. Initial processing of human bone allografts typically involves stripping the bone of its soft tissue and sectioning it into smaller, more manageable pieces of approximately 5 mm in diameter. After the technician has cleansed the bone of soft tissue and has decontaminated it, proprietary processing takes place via one of many paths; some tissue-processing techniques involve liquid nitrogen freezing followed by lyophilization, whereas oth-ers involve repetitious wash treatments with solvents such as acetone. Although different, these procedures

Table 2.1 (continued)

Reconstructive procedure

Systematic reviews

Outcome No. of studies

Weighted mean difference (mm)

95% CI (SD) [SE]

P-value for difference

P-value for heterogeneity

Porous ⁄ nonporous hydroxyapatite


CAL change 4 1.40 0.64, 2.16 <0.001 0.013

PD change 5 0.98 0.67, 1.29 <0.000 0.070


CAL change 4 1.20 (2.22) 0.003 NS

PD change 6 0.74 (2.12) 0.030 NS

Bone fill 5 1.58 (1.77) <0.000 £0.04

PMMA-PHEMA Trombelli et al. (2002)

CAL change 1 0.90 [0.22] 0.001 –

PD change 1 0.90 N ⁄ A 0.003 –


Bone fill 1 1.26 N ⁄ A 0.001 –

Polylactic acid granules


CAL change 1 −1.45 N ⁄A N⁄A –

PD change 1 −1.60 (0.55) N ⁄A –


Bone fill 1 −0.28 N ⁄ A 0.519 –

Enamel matrix proteins


CAL change 5 1.33 0.78, 1.88 <0.000 <0.001

PD change 5 1.60 0.59, 2.62 0.002 <0.001

Esposito et al. (2003)

CAL change 8 1.31 0.84, 1.78 <0.001 <0.001

PD change 8 0.96 0.50, 1.41 <0.001 0.002

Radiographic bone level

1 2.0 0.88, 3.12 <0.001 –

Source: Trombelli et al. (2005). Reprinted with permission from John Wiley & SonsCAL clinical attachment level, CI confidence interval, GTR guided tissue regeneration, PD probing depth, PMMA-PHEMA polym-ethylmethacrylate and polyhydroxylethylmethacrylate, SD standard deviation, SE standard error, NS not significant*P values are not given for Needleman et al. (2001) because the 95% confidence interval was reported


produce similar results by eliminating nearly all of the moisture content from the bone, reducing antigenic-ity and facilitating extremely lengthy shelf storage at room temperature. If the final product is a freeze-dried bone allograft (FDBA), processing technicians reduce the processed bone to a particle size usually ranging between 250 and 750 mm, resample it for quality con-trol, package it in sterile containers and may terminally sterilize it with low-dose g irradiation (Table 2.2). If the final product is intended to be a demineralized freeze-dried bone allograft (DFDBA), the technician typi-cally immerses the bone in a hydrochloric acid bath for various lengths of time to demineralize the bone by removing calcium. After acid treatment, the techni-cian washes the newly demineralized bone allograft in

various buffer solutions to remove residual acid, rinses it to remove the buffer and terminally processes it in a fashion similar to that used for FDBA (Table 2.3).

Processing step 1. Soft tissue strippingThe technician removes residual muscle, tendon, ligament and so forth.

Processing step 2. Initial size reductionThe technician reduces the bone to pieces of approximately 5 mm diameter for easier processing.

Processing step 3. Initial cleansing and decontaminationThe technician flushes, agitates, centrifugates or does all of these to the bone particles using various solutions such as saline, acetone, ethanol or hydrogen peroxide to remove residual bioburden and reduce antigenicity.

Processing step 4. Microbiological treatmentThe technician treats the bone particles with antimicrobial, antimycotic and antifungal solutions.

Processing step 5. FreezingThe technician freezes the bone particles in liquid nitrogen of a temperature as low as −80°C.

Processing step 6. DehydrationThe technician lyophilizes or treats the bone particles with repetitive solvent washes to eliminate moisture content and reduce antigenicity.

Processing step 7. Secondary size reductionThe technician reduces the bone particles to final particulate sizes ranging between approximately 250 and 750 mm.

Processing step 8. PackagingThe technician packages the bone allograft in sterile containers.

Processing step 9. Terminal sterilizationThe technician applies low-dose g irradiation at low tempe ratures to ensure sterility (sterility assurance level, 10–6).

Table 2.2 Steps in the processing of freeze-dried bone allograft (Holtzclaw et al. 2008) (Copyright © 2008 American Dental Association. All rights reserved. Reproduced by permission)

Processing step 1. Soft tissue strippingThe technician removes residual muscle, tendon, ligament and so forth.

Processing step 2. Initial size reductionThe technician reduces the bone to pieces of approximately 5 mm diameter for easier processing.

Processing step 3. Initial cleansing and decontaminationThe technician flushes, agitates, centrifugates or does all of these to the bone particles using various solutions such as saline, acetone, ethanol or hydrogen peroxide to remove residual bioburden and reduce antigenicity.

Processing step 4. Microbiological treatmentThe technician treats the bone particles with antimicrobial, antimycotic and antifungal solutions.

Processing step 5. FreezingThe technician freezes the bone particles in liquid nitrogen of a temperature as low as −80°C.

Processing step 6. DehydrationThe technician lyophilizes or treats the bone particles with repetitive solvent washes to eliminate moisture content and reduce antigenicity.

Processing step 7. Secondary size reductionThe technician reduces the bone particles to final particulate sizes ranging between approximately 250 and 750 mm.

Processing step 8. DemineralizationThe technician immerses the allograft particles in a hydrochloric acid bath at concentrations ranging from 0.5 to 0.6 normal for various lengths of time.

Processing step 9. BufferingThe technician again immerses the demineralized allograft particles in buffering solution to remove residual acid.

Processing step 10. Final rinseThe technician again rinses the demineralized allograft with various solutions (e.g., distilled water) to remove residual buffer solution.

Processing step 11. PackagingThe technician packages the bone allograft in sterile containers.

Processing step 12. Terminal sterilizationThe technician applies low-dose g irradiation at low temperatures to ensure sterility (sterility assurance level 10–6).

Table 2.3 Steps in the processing of demineralized freeze-dried bone allograft (Holtzclaw et al. 2008) (Copyright © 2008 American Dental Association. All rights reserved. Reproduced by permission)

812.2 Allografts

Thus, rigorous donor screening and aseptic proprietary processing programs have rendered the use of human bone allografts safe and effective as a treatment option (Holtzclaw et al. 2008).

2.2.1 Freeze-Dried Bone Allografts (FDBA)

FDBA, which is not demineralized, works primarily through osteoconduction, a process in which the graft does not activate bone growth, but instead acts like a scaffold for the patient’s own natural bone to grow onto and within. Over time, the graft is resorbed and replaced by new bone (Rosenberg and Rose 1998; Nasr et al. 1999).

FDBA is also a useful material clinically. There have been no reports of virus contamination or acquired pathology from FDBA, although this mate-rial is in wide use clinically (Committee on Research, Science and Therapy of the American Academy of Periodontology 2001). It was used in the treatment of three-wall intrabony defects adjacent to implants in dogs (Choi et al. 2010), in maxillary sinus-augmen-tation procedures (Kolerman et al. 2008), in alveolar ridge augmentation alone (Fagan et al. 2008) or asso-ciated with platelet-rich plasma (Kassolis et al. 2000), in the treatment of periodontal defects, alone (Nevins et al. 2007; Laurell et al. 1998), combined with enamel matrix derivative (Rosen and Reynolds 2002) or with barrier membrane (Rosen and Reynolds 2001). FDBA can be combined with antimicrobial therapy, and has been used with tetracycline to regenerate experimental defects in baboons (Drury and Yukna 1991) or during treatment of localized juvenile periodontitis (Evans et al. 1989; Mabry et al. 1985). FDBA may be regarded as a graft material lacking clinically significant antige-nicity (Quattlebaum et al. 1988).

2.2.2 Demineralized Freeze-Dried Bone Allografts (DFDBA)

Demineralization of a bone allograft exposes bone morphogenetic proteins within the bone matrix. These inductive proteins induce a cascade of events leading to cellular differentiation and the formation of bone

through osteoinduction by inducing pleuripotential stem cells to differentiate into osteoblasts (Mellonig et al. 1992; Nasr et al. 1999).

It is important to evaluate the methods, procure-ment, processing and particle size of the demineralized freeze-dried bone allograft used in a study. When DFDBA is used in particulate form, particle size appears to be an important variable in the success of DFDBA as a bone-inductive material. Particles in the range of 125–1,000 mm possess a higher osteogenic potential than do particles below 125 mm. Optimal par-ticle size appears to be between 100 and 300 mm. This may be due to a combination of surface area and pack-ing density. Very small DFDBA particles elicit a mac-rophage response and are rapidly resorbed with little or no new bone formation. Tissue banks providing DFDBA for dental use will usually have this graft material in various particle sizes, and the range from 250 to 750 mm is the most frequently available (Committee on Research, Science and Therapy of the American Academy of Periodontology 2001). Schwartz et al. (1996) had shown a wide variation in commercial bone bank preparation of demineralized freeze-dried bone allograft and the ability to induce new bone formation. Particle size before implantation correlated with particle size after implantation. However, particle size did not correlate with ability to induce bone. The results show that commercial DFDBA differs in both size and ability to induce new bone formation, but that the two are not related.

Donor variability, however, also limits the predict-ability of DFDBA as an osteoinductive material (Boyan et al. 2006). The ability to induce bone appears to be age dependent, with DFDBA from older donors being less likely to have strong bone-inducing activity (Schwartz et al. 1998a).

The degree of DFDBA demineralization varies between tissue banks and may also affect clinical regeneration. A 2% residual calcium level in DFDBA has been shown to result in the highest alkaline phos-phatase activity levels in cultured human periosteal cells and is optimally osteoinductive or osteoconduc-tive for new bone formation (Herold et al. 2002).

Histological studies in humans performed by Bowers et al. (1989a, 1989b) revealed the formation of new attachment apparatus in intrabony defects grafted with DFDBA. At this time, demineralized freeze-dried bone allograft remains the only bone replacement graft proven to result in periodontal regeneration in a


controlled human histological study and is recognized in the consensus report by the 1996 World Workshop in Periodontics to fulfill all criteria considered for the promotion of periodontal regeneration (Nasr et al. 1999). The ability of demineralized bone to induce new bone formation in soft tissues and to enhance bone formation in osseous tissues is believed to be due to the content and diffusibility of bone morphogenetic pro-teins (BMPs) present in the material (Lohmann et al. 2001). The BMPs and other growth factors and cytok-ines interact with mesenchymal stem cells or undiffer-entiated osteogenic precursors in the host tissue, causing them to differentiate into bone-forming cells (Li et al. 2000; Lohmann et al. 2001; Schwartz et al. 1998b). Several other growth factors were identified: FGFa (fibroblast growth factor), IGF-I (insulin-like growth factor-I), TGF-b1 (transforming growth factor-beta1), VEGF (vascular endothelial growth factor) and PDGF (platelet-derived growth factor) (Wildemann et al. 2007).

Six studies (Altiere et al. 1979; Blumenthal and Steinberg 1990; Borghetti et al. 1993; Flemmig et al. 1998; Masters et al. 1996; Yukna et al. 1998) compar-ing bone allograft with open flap debridement (OFD) procedure were included and pooled for meta-analysis by Trombelli et al. (2002). The results showed a lim-ited, not statistically significant, greater CAL gain for grafted group with respect to OFD. Weighted mean difference between grafted and control was 0.36 mm (95% CI: −0.16 to 0.87; Q-test for heterogeneity, 14.40 (df = 5), P = 0.01). A significantly greater probing depth reduction was reported for bone allograft treat-ment: 0.41 mm (95% CI: 0.16–0.66) compared to OFD. Meta-analysis performed by Reynolds et al. (2003) on 12 studies (Altiere et al. 1979; Blumenthal and Steinberg 1990; Borghetti et al. 1993; Brown et al. 1998; Flemmig et al. 1998; Mabry et al. 1985; Masters et al. 1996; Meadows et al. 1993; Mellonig 1984; Mora and Ouhayoun 1995; Schrad and Tussing 1986; Yukna et al. 1998) showed a greater clinical attachment level gain for the grafted group with respect to OFD. Weighted mean difference between graft and control was 0.44 mm (SD 2.25). Adjunctive defect fill amounted to 1.06 mm (SD 1.97) with the use of bone allograft. A significantly greater probing depth reduc-tion was reported for bone allograft treatment 0.43 mm, SD 2.25 compared to OFD (Fig. 2.5).

It may be possible to enhance the amount of bone fill obtained with bone replacement grafts such as DFDBA by combining regenerative therapies (Hanes 2007). The use of replacement grafts (DFDBA) in an aim to improve the results of GTR therapy for the treatment of intrabony or mucogingival defects was evaluated by several studies (Chen et al. 1995; Trejo et al. 2000; Lamb et al. 2001; Duval et al. 2000; Wang et al. 2002; Couri et al. 2002; Bowers et al. 2003; Kimble et al. 2004; Aichelmann-Reidy et al. 2004; Kothiwale et al. 2009). In studies where demineralized freeze-dried bone has been combined with barriers of cross-linked bovine collagen or expanded polytetrafluoroethylene membranes, the results tend to indicate that combined therapy is also a successful therapeutic approach (Rosen et al. 2000).

Recent studies suggest that the addition of enamel matrix derivative (EMD) to demineralized freeze-dried bone allograft may enhance osteoinduction (Boyan et al. 2000, 2006; Rosen and Reynolds 2002; Gurinsky et al. 2004; Harris et al. 2007; Hoidal et al. 2008; Aspriello et al. 2010). Venezia et al. (2004) concluded that EMD combination with allograft materials may be of additional benefit but still needs to be further investigated. Emdogain is composed primarily of amelogenin and other proteins present in embryonic porcine tooth germs. It is possible that a trace compo-nent of Emdogain possesses osteoinductive properties. During embryonic development, the interaction of epi-thelial and mesenchymal tissues is critical for tissue morphogenesis. It was suggested that Emdogain abil-ity to enhance the osteoinductivity of DFDBA is the result of its properties as a bioactive matrix. Emdogain also delayed the rate at which DFDBA was resorbed, suggesting that factors present in thus complex agent might modulate bone remodeling in addition to bone formation (Boyan et al. 2006). In contrast with previ-ous results, it was also reported that DFDBA combined with EMD compared to DFDBA alone in the treat-ment of intraosseous defects of chronic periodontitis provided no statistically significant improvement to the soft and hard tissue parameters measured (Hoidal et al. 2008).

Several authors have investigated the impact of growth factors to demineralized freeze-dried bone allograft (DFDBA) (Bowers et al. 1991; Danesh-Meyer et al. 2001; Mott et al. 2002; Markopoulou

832.2 Allografts

Fig. 2.5 (a) Preoperative view of the mandibular left canine in a 39-year-old Caucasian woman. The patient is a nonsmoker. (b) Preoperative radiograph suggests that there is an intrabony lesion at the distal of the left premolar. (c) Full-thickness flap reflection reveals a combination two- and three-wall lesion. (d) After root planing, scaling, citric acid root surface treatment and intramarrow penetration, demineralized freeze-dried bone allograft is placed to fill the entire defect. (e) View of the site at 48 months postsurgery. There has been some loss in height of the interdental papilla. (f) Postoperative radiograph taken at 48 months suggests complete bone fill of the defect at the distal of the canine. (g) Reentry performed at 48 months postsurgery shows hard tissue fill of the defect. There has been a slight loss of facial bone on the cuspid (Rosen et al. 2000) (Reprinted with permission from John Wiley & Sons)


et al. 2003; Camelo et al. 2003; Papadopoulos et al. 2003; Nevins et al. 2003a, 2007; Dereka et al. 2006, 2009; ; Markou et al. 2009, 2010). It has been showed that addition of BMP-2 increased osteoinduction of DFDBA by almost 50% based on the bone induction score (Boyan et al. 2006). DFDBA contains BMP-2, but the amount seems to vary among individuals. Moreover, the formatting of BMP-2 within DFDBA is different from that of BMP-2 adsorbed to the sur-face of the graft particles. Studies suggest that the DFDBA particles must be resorbed for the BMP con-tained within the matrix to be released. DFDBA becomes, in effect, a time-release carrier for these factors. Surface-adsorbed BMP-2 is released in a burst and, as a result, has its greatest effects on cells present at the implant site. Thus, the two forms of the morphogen work on distinctly different cell popula-tions, and the combined effect is additive, if not syn-ergistic. Other factors present in DFDBA also may contribute to the overall tissue response (Boyan et al. 2006). The evaluation of the effect of a combination of BMPs with a graft/bone substitute relates to one single histomorphometric study in humans where the association of BMP-3 (osteogenin) and two different biomaterials (purified bovine collagen and DFDBA) has been evaluated (Bowers et al. 1991). Test treat-ments consisted of the association of BMP-3 with DFDBA or bovine collagen; control groups consisted of the grafts used alone. Histologic evaluation at 6 months indicated that osteogenin combined with DFDBA significantly enhanced regeneration of a new attachment apparatus and component tissues in a sub-merged environment. DFDBA plus osteogenin and DFDBA alone formed significantly more new attach-ment apparatus and component tissues than either the tendon-derived matrix plus osteogenin or the tendon-derived matrix alone in both submerged and nonsub-merged environments. There were no significant differences between the tendon-derived matrix plus osteogenin and the tendon-derived matrix alone in either the submerged or nonsubmerged environment (Bowers et al. 1991). The combination of BMPs and allograft is a promising step forward in improving allograft treatment. As the number of allograft proce-dures performed per year increases worldwide, the outcome for many could be influenced by the addition of BMPs. Still, safety concerns as well as availability

of allograft is a continuous source of inspiration for those investigating alternative bone sources (Blokhuis and Lindner 2008).

Osteoblast proliferation rates indicate that the in vitro supplementation of 2% residual calcium-DFDBA with the combination of insulin-like growth factor (IGF) and transforming growth factor-b (TGF-b), IGF and platelet-derived growth factor (PDGF), and PDGF and TGF-b significantly (P £ 0.05) enhances murine osteoblast activity and proliferation at 7 days compared with the control containing no exogenous growth factors (Mott et al. 2002). In contrast with these reports and to the increase in osteoinduction seen when DFDBA is implanted with BMP-2 or Emdogain, PDGF and PRP reduced osteoinductivity by approximately 20%. The inhibitory effect of PDGF-BB on DFDBA-induced bone formation is concentration dependent and, at high concentrations, causes the chondroge-nic phase of endochondral bone formation to persist. At low concentrations, PDGF-BB does not inhibit DFDBA activity and, in an orthotopic site where other osteogenic signals are present, its effect on mesenchy-mal cell proliferation may result in increased bone for-mation (Boyan et al. 2006). Nevins et al. (2003a) revealed a robust regeneration of a complete new attachment apparatus, including bone, periodontal lig-ament and cementum in human interproximal intrabony defects and molar Class II furcation lesions following the application of purified recombinant human plate-let-derived growth factor BB (rhPDGF-BB) incorpo-rated in demineralized freeze-dried bone allograft (DFDBA) (Nevins et al. 2003a). In a randomized, dou-ble-masked, clinical trial, Piemontese et al. (2008) compared platelet-rich plasma (PRP) combined with a demineralized freeze-dried bone allograft (DFDBA) to DFDBA mixed with a saline solution in the treatment of human intrabony defects. No statistically significant differences were observed in the hard tissue response between the two treatment groups, which confirmed that PRP had no effect on hard tissue fill or gain in new hard tissue formation. It was recently demonstrated that both PRP and PRP combined with DFDBA resulted in significant clinical and radiographic improvement in human periodontal endosseous defects at 6 and 12 months (Piemontese et al. 2008; Markou et al. 2009, 2010), and the addition of DFDBA to PRP did not significantly enhance the treatment outcome

852.3 Xenografts

(Markou et al. 2009). A recent randomized, double-masked, clinical trial compared platelet-rich plasma (PRP) combined with a demineralized freeze-dried bone allograft (DFDBA) to DFDBA mixed with a saline solution in the treatment of human intrabony defects. The test group (PRP + DFDBA) exhibited sta-tistically significantly greater changes compared to the control group in probing depth reduction (4.3 ± 1.7 mm versus 2.6 ±2.2 mm; P < 0.05) and clinical attachment gain (3.5 ± 2.1 mm versus 2.3 ± 2.4 mm; P < 0.001). No statistically significant differences were observed in the hard tissue response between the two treatment groups (Piemontese et al. 2008).

Demineralized bone matrix is produced by acid extraction of allograft. It contains type-1 collagen, non-collagenous proteins and osteoinductive growth factors. There are numerous demineralized bone matrix formu-lations based on refinements of the manufacturing pro-cess. They are available as freeze-dried powder, granules, gel, putty or strips. They have also been devel-oped as combination products with other materials such as allogeneic bone chips and calcium sulfate granules (De Long et al. 2007). Demineralized bone matrix paste and putty are particulate demineralized bone matrices in a 2% or 4% hyaluronate carrier, respectively. When compared with demineralized freeze-dried bone allo-grafts, all demonstrated similar favorable improvements in soft and hard tissue parameters in the treatment of human intraosseous defects (Bender et al. 2005).

Examples of commercially available prod-ucts are Grafton® DBM (Osteotech, Inc. American Association of Tissue Banks), Grafton Plus® DBM Paste (Osteotech, Inc. American Association of Tissue Banks), Osseograft (Advanced Biotech Products (P) Ltd. India), Accell ConnexusTM (Accell® technol ogy + DBM particles + reverse phase medium for opti-mal handling) (IsoTis Orthobiologics/GenSci Rege-neration Technologies), Accell® DBM100® (Accell® technology + DBM particles in putty) (IsoTis Ortho-biologics/GenSci Regeneration Technologies), DBX® Demineralized Bone Matrix (Musculoskeletal Transplant Foundation, USA), Dynagraft putty (Gen-Sci, Regene-ration Laboratories, CA) and Osteofil allograft bone paste (Regeneration Technologies, FL). Regenafil®, Altiva DBM Paste, BioSetTM, RTI Allograft Paste and Osteofil® contain human demineralized freeze-dried bone allograft (DFDBA, also known as demineralized

bone matrix, DBM) in an inert porcine gelatin car-rier. Regenaform®, Altiva DBM with cortical cancel-lous chips, BioSetTM IC, RTI Allograft Paste IC and Osteofil® ICM contain human DFDBA and human cortical-cancellous bone chips in an inert porcine gela-tin carrier. Regenafil and Regenaform Frozen Allograft Paste should be stored frozen. It may be stored for 6 months at −20 to −40°C (conventional freezer) or up to 5 years if stored at −40°C or colder (see expira-tion date on label). Regenafil and Regenaform Frozen Allograft Paste must be warmed prior to use. Detailed instructions for warming the graft are included in the package insert that accompanies each graft (http://www.exac.com/products/dental-biologics).

The decision about which form of allograft to use should be based on the clinical condition of the site to be grafted. Because it is still mineralized, FDBA may have better physical characteristics. However, FDBA is not osteoinductive. Although no significant differ-ences have been found clinically between FDBA and DFDBA in primarily intraosseous defects (Piattelli et al. 1996a; Rummelhart et al. 1989; Francis et al. 1995) in sites where regeneration may be more prob-lematic, DFDBA may be a more appropriate choice (Committee on Research, Science and Therapy of the American Academy of Periodontology 2001). However, recent histological study suggested that FDBA may stimulate earlier, more rapid and more substantial new bone formation than DFDBA in a monkey jaw defect model system (Yukna and Vastardis 2005). A trend was observed toward greater improve-ment in clinical attachment level gain in advanced infrabony defects when EMD was combined with FDBA (57.3% ± 9.4%) as compared to DFDBA (49.1% ±11.0%) (Rosen and Reynolds 2002).

2.3 Xenografts

Xenografts are grafts shared between different species. Currently, there are two available sources of xenografts used as bone replacement grafts in periodontics: bovine bone and natural coral. Both sources, through different processing techniques, provide products which are biocompatible and structurally similar to human bone. Recently, porcine bine xenografts have also been described. Xenografts are osteoconductive, readily


available and risk free of disease transmission. The lat-ter point has been questioned with the discovery of bovine spongiform encephalopathy, particularly in Great Britain (Nasr et al. 1999).

2.3.1 Anorganic Bovine-Derived Bone Xenograft (BDX)

The BDX is a xenograft consisting of deproteinized, sterilized bovine bone with 75–80% porosity and a crystal size of approximately 10 mm in the form of cor-tical granules (Hürzeler et al. 1997; Piattelli et al. 1999). Regarding both the chemical and physical fea-tures, BDX is considered identical to the human bone (Berglundh and Lindhe 1997; Piattelli et al. 1999).

BDX has several characteristics and advantages when compared with freeze-dried demineralized bone: no donor site is required from the patients; unlimited supplies of the material are available; the material is easily handled and used as freeze-dried demineralized bone; and the results are predictable when good surgi-cal principles are observed, a sterile environment is maintained and tissue is handled properly as recom-mended by the manufacturer (Callan et al. 1993).

Xenografts are bovine in origin and carry the theo-retical risk of transmission of bovine spongiform encephalopathy (Precheur 2007). Several studies, how-ever, indicate that the use of these materials does not carry a risk for transmitting bovine spongiform enceph-alopathy (BSE) to humans (Hönig et al. 1999; Wenz et al. 2001; Precheur 2007). Sogal and Tofe (1999) conducted an extensive review of current literature on the status of risk assessment of BSE transmission and two risk assessment models were identified as appli-cable to the present study. Risk assessment models developed by the German Federal Ministry of Health and by the Pharmaceutical Research and Manufacturers Association of America were applied to BGS. Results from the analyses conducted using both models showed that the risk of disease (BSE) transmission from BGS was negligible and could be attributed to the stringent protocols followed in sourcing and processing of the raw bovine bone used in the commercial product.

Several histological studies in animals and humans have revealed that BDX possesses excellent

osteoconductive properties (Berglundh and Lindhe 1997; Skoglund et al. 1997; Camelo et al. 1998, 2001; Hämmerle et al. 1998; Mellonig 2000; Zitzmann et al. 2001; Paolantonio 2002; Nevins et al. 2003a, 2003b; Sculean et al. 2003b, 2004a). The large-mesh intercon-necting pore system facilitates angiogenesis and migra-tion of osteoblasts (Orsini et al. 2005). Several histological studies have shown that BDX particles were surrounded for the most part by mature, compact bone. In some Haversian canals, it was possible to observe small capil-laries, mesenchymal cells and osteoblasts in conjunction with new bone. No gaps were present at the interface between the BDX particles and newly formed bone, the BDX granules being interconnected by bridges of vital newly formed bone (Piattelli et al. 1999; Tadjoedin et al. 2003). With time, BDX becomes integrated and subse-quently replaced by newly formed bone (Berglundh and Lindhe 1997). In histological specimens retrieved after 18 months and 4 years, it was possible to observe the presence of osteoclasts in the process of resorbing the BDX particles and neighboring newly formed bone (Piattelli et al. 1999). It has been reported that BDX has a very low resorption rate (Valentini and Abensur 1997). However, how this biomaterial enhances osteoblast activ-ity to promote bone formation is not completely under-stood. MicroRNAs (miRNAs) represent a class of small, functional, noncoding RNAs of 19–23 nucleotides that regulate the transcription of messenger RNAs (mRNAs) in proteins. The miRNA microarray technique was used to investigate translation regulation in an osteoblast-like cell line (MG63) exposed to Bio-Oss. It was showed that the vast majority of detected mRNAs were downregu-lated, including some homeobox genes (genes that regu-late the morphogenesis of an entire segment of the body), such as noggin and EN1. An indirect positive effect was demonstrated on bone morphogenetic protein-4 (Palmieri et al. 2010). It was indicated that BDX and Perioglas act on different miRNAs. Globally, Perioglas causes activa-tion of bone-forming signaling, whereas BDX also acti-vates cartilage-related pathways (Annalisa et al. 2008).

Because all the protein is removed, this 100% crystalline hydroxyapatite grafting material is consid-ered biocompatible (Cohen et al. 1994; Callan et al. 1993), is very well tolerated, and, until now, no adverse reactions such as allergies or rejection of the graft particles related to the material have been reported (Camelo et al. 1998; Richardson et al. 1999;

872.3 Xenografts

Camargo et al. 2000; Mellonig 2000; Zitzmann et al. 2001; Sculean et al. 2003, 2004a, 2004b, 2005a, 2005b, 2007b; Tonetti et al. 2004; Liñares et al. 2006). However, recently, Bannister and Powell (2008) pre-sented an unusual reaction to BDX after a ridge augmenta tion by a mixture of autogenous bone and anorganic bovine bone with platelet-rich plasma and a bioabsorbable collagen membrane. Healing was uneventful, although after 4 months, upon flap reflec-tion, no regenerated hard tissue was found. At the his-tologic examination, it was observed that the majority of the graft material demonstrated an intimate asso-ciation with multinucleated foreign body-type giant cells. However, at the second procedure, the site was regrafted with an allograft/xenograft mixture and covered by a bioabsorbable collagen membrane and wound healing was uneventful.

BDX has demonstrated efficacy for:

• Reconstruction of atrophied alveolar ridges (Callan and Rohrer 1993; Artzi and Nemcovsky 1998; Zitzmann et al. 2001; Kotschy and Laky 2006; Esposito et al. 2006; Cardaropoli et al. 2005; Lang et al. 2007)

• Around endosseous implants (Berglundh and Lindhe 1997; Skoglund et al. 1997; Zitzmann et al. 1997; Hämmerle et al. 1998; Schlegel and Donath 1998; Juodzbalys and Wang 2007)

• Sinus elevation floor procedures (Valentini et al. 1998, 2000; Valentini and Abensur 2003; Piattelli et al. 1999; Hallman et al. 2001; Wallace and Froum 2003; Orsini et al. 2005; Handschel et al. 2009; Bornstein et al. 2008; Beloti et al. 2008)

• Healing of intrabony peri-implantitis defects (Schou et al. 2003; Schwarz et al. 2006a, 2008, 2009; Esposito et al. 2008)

• Periradicular surgery in large periapical lesions (Dietrich et al. 2003; Taschieri et al. 2007)

• Periodontal bone defects where BDX has been evaluated when used alone (Hutchens 1999; Richardson et al. 1999; Scheyer et al. 2002; Scabbia and Trombelli 2004; Gupta et al. 2007), in associa-tion with membranes (Hutchens 1999; Camelo et al. 1998, 2001; Camargo et al. 2000; Simonpietri-C et al. 2000; Paolantonio et al. 2001; Pietruska 2001; Paolantonio 2002; Sculean et al. 2003, 2004a, 2005a, 2007b; Stavropoulos and Karring 2005;

Stavropoulos et al. 2003; Stavropoulos et al. 2004; Vouros et al. 2004; Tonetti et al. 2004; Reddy et al. 2006; Sakata et al. 2006; Liñares et al. 2006) and in combination with enamel matrix protein derivative (Lekovic et al. 2000; Lekovic et al. 2001; Scheyer et al. 2002; Velasquez-Plata et al. 2002; Zucchelli et al. 2003; Sculean et al. 2002b, 2004b)

A composite of autogenous bone and bone substitute is widely used in oral surgery procedures because it combines the osteogenic property of autogenous bone and the osteoconductive property of BDX (Fig. 2.6). It contains osteogenic cells and provides a scaffold and internal pores for bone cells to grow and remineralize to new bone. The relative proportions of autogenous bone and bone substitute vary (Pripatnanont et al. 2009). A systematic review recommended a propor-tion of 1:2 (Merkx et al. 2003). Pripatnanont et al. (2009) assessed new bone formation generated using three different proportions of autogenous bone (AB) and deproteinized bovine bone (BDX) in cortical skull defects in rabbits. The 1:2 group had significantly higher bone content than the 1:4 group. The propor-tions of 1:1 and 1:2 resulted in greater bone formation than the proportion of 1:4 (Pripatnanont et al. 2009). In deep intrabony defects treatment, at 12 months eval-uation, the combined use of autogenous spongiosa with bovine-derived xenograft led to significantly greater gain of clinical attachment and hard tissue for-mation compared to the use of autogenous spongiosa alone (Zafiropoulos et al. 2007).

Examples of commercially available bovine-derived bone replacement grafts are Bio-Oss® (Osteohealth Co., Shirley, NY), Bio-Oss Collagen® (Osteohealth Co., Shirley, NY), OsteoGraf/N® (CeraMed Dental, LLC, Lakewood, CO) and PepGen P-15® (Dentsply Friadent, Mannheim, Germany) (Sukumar and Drízhal 2008).

Bio-Oss® (Osteohealth Co., Shirley, NY) is a natural, nonantigenic, porous bone mineral matrix. It is pro-duced by the removal of all organic components from bovine bone (Fig. 2.7). It is available in cancellous (spongiosa) and cortical granules and blocks. Bio-Oss undergoes a low-heat (3,000°C) chemical extraction process by which all organic components are removed, but maintains the natural architecture of bone (Richardson et al. 1999). This material is essentially


Fig. 2.6 Proportion of deproteinized bovine bone and autogenous bone affects bone formation in the treatment of calvarial defects in rabbits: (a) a critical size defect, (b) an autogenous bone chip, (c) BDX alone, (d) a composite graft of autogenous bone and BDX at 1:1 ratio, (e) a composite graft of autogenous bone and

BDX at 1:2 ratio, (f) a composite graft of autogenous bone to BDX at 1:4 ratio. White arrows indicate new bone, black arrows indicate bone chips, black stars indicate BDX particles (Hematoxylin and Eosin, original magnification ×10) (Pripatnanont et al. 2009) (Reprinted with permission from Elsevier)

carbonate-containing apatite with few hydroxyl groups, and possesses a crystalline architecture and calcium:phosphate ratio similar to natural bone mineral in humans (Cohen et al. 1994). Due to its natural struc-ture Bio-Oss is physically and chemically comparable to the mineralized matrix of human bone (Fig. 2.8). Chemically, Bio-Oss is a low crystalline apatite (crys-tallite size of approximately 100 × 200 × 500 Å) with a

7% content of carbonate (Benke et al. 2001). The infra-red spectra and X-ray diffraction patterns show a cal-cium content of 37.1 ± 0.7% and a phosphorous content of 17.8 ± 0.5%, corresponding to a Ca–P ratio of 2.1 ± 0.1 (Jensen et al. 1996; Scabbia 2004 Sculean et al. 2007b).

Bio-Oss Collagen® (Osteohealth Co., Shirley, NY) consists of Bio-Oss Spongiosa granules (0.25–1 mm)

892.3 Xenografts

with the addition of 10% highly purified porcine colla-gen. As with Bio-Oss, the mineral structure of Bio-Oss Collagen is highly porous, possesses a large internal surface area and functions as a scaffold for bony ingrowth. The collagen component enables convenient handling and simple application but does not function as a barrier. The collagen component allows Bio-Oss Collagen to be easily adapted into the defect. The cohe-sion of the particles is ensured, even without a mem-brane. The collagen component is resorbed within 4–6 weeks (http://www.osteohealth.com). Bio-Oss Collagen has the capacity to facilitate regeneration of the periodontal attachment apparatus when placed in intrabony defects (Nevins et al. 2005b). No differences in the histological findings were observed following treatment of human intrabony defects with either a bovine-derived xenograft and GTR or a bovine-derived

xenograft mixed with collagen and GTR. Healing was characterized by the formation of new cementum, new periodontal ligament and new bone (Figs. 2.9 and 2.10). Most of the graft particles were surrounded by bone, which in turn points to the highly osteoconductive potential of the graft material (Sculean et al. 2004a).

OsteoGraf/N® (CeraMed Dental, LLC, Lakewood, CO) is a pure, natural form of hydroxylapatite, the major mineral component of tooth enamel and bone. OsteoGraf/N is completely biocompatible and remod-els to vital bone at the same rate as host bone.

Fig. 2.7 Bio-Oss® (Osteohealth Co., Shirley, NY)

Fig. 2.8 SEM photographs of deproteinized bovine bone (DBB) granules showing the pore structure, size 200–500 mm (original magnification, ×400) (Pripatnanont et al. 2009) (Reprinted with permission from Elsevier)

Fig. 2.9 Healing of human intrabony defects following regenera-tive periodontal therapy with a bovine-derived xenograft and guided tissue regeneration. Representative histologic view of a healing following treatment with bovine-derived xenograft (BDX) Collagen + guided tissue regeneration (GTR). The healing occurred in formation of new cementum with inserting collagen fibers (C) and new bone (NB) coronally to the notch (N) in the root surface. BDX (G) particles are surrounded by bone. A artifact (Original magnification ×50: van Giesson’s connective tissues stain) (Sculean et al. 2004a) (Reprinted with permission from Springer)


OsteoGraf/N is the only xenograft that meets all ASTM standards for “Composition of Anorganic Bone for Surgical Implants (F1581-95).” The product is hydro-philic – cohesive consistency when hydrated. It is manufactured as radiopaque, rounded particles and is available in two particle sizes:

OsteoGraf/N-300 (250–420 • mm) packaged in 1-g and 3-g vialsOsteoGraf/N-700 (420–1,000 • mm) packaged in 1-g and 3-g vials

A unique regenerative product is PepGen P-15® (Dentsply Friadent, Mannheim, Germany), a calcined bovine bone (1,100°C; hydroxyapatite) coated with a pentadecapeptide (P-15, a part of the sequence of col-lagen). It is available as granulate with a particle size of 0.25–0.42 mm and used in dental applications (Tadic and Epple 2004). The product is described in more detail in Chap. 5.

2.3.2 Anorganic Porcine-Derived Bone Xenograft

A natural replicate of autologous bone, OsteoBiol® Gen-Os (Tecnoss Dental, Turin, Italy) conserves the same intimate structures (matrix and porous form) and presents a high osteoconductive activity (Fig. 2.11). It is biocompatible and bioavailable, as recognized by tests made according to the ISO 10993 method con-ducted at the Università degli Studi di Torino. Gen-Os is gradually resorbable and provides support in bone neoformation helping to preserve the original graft shape and volume (osteoconductive property). Moreover, thanks to its collagen content, the product facilitates blood clotting and the subsequent invasion of repairing and regenerative cells, favoring restitutio ad integrum of missing bone. Because of its marked “hydrophilia,” it can function as a carrier for selected medication and drugs. Gen-Os must always be hydrated and thoroughly mixed with a few drops of sterile phys-iological solution to activate its collagen matrix and to enhance its adhesivity; it can also be mixed either with OsteoBiol Gel or with patient’s blood. If necessary it can as well be mixed with the drug selected for surgery. Gen-Os expands up to 50% in volume after hydration with sterile saline: hydrated collagen contained in each granule also increases sensibly biomaterial adhesivity (http://www.osteobiol.com/products.php). The particle sizes of the commercialized product are 250–1,000 mm and its porosity 33% (Figueiredo et al. 2010).

The material showed good clinical results when used for augmentation of the alveolar crest and maxil-lary sinus (Pagliani et al. 2010; Barone et al. 2010), as a filler in postextractive alveolus (Arcuri et al. 2005) and for implant treatment (Fernández et al., 2011;

Fig. 2.10 Healing of human intrabony defects following regen-erative periodontal therapy with a bovine-derived xenograft and guided tissue regeneration. High-power magnification of the regenerated area shown in Fig. 2.9. Bovine-derived xenograft (BDX) particle (G) is surrounded by bone. C new cementum, NPL new periodontal ligament, NB new bone (Original magnifi-cation ×250: van Giesson’s connective tissues stain) (Sculean et al. 2004a) (Reprinted with permission from Springer)

912.3 Xenografts

Calvo Guirado et al., 2011). Clinical and histological study suggest that the use of a mixture of collagen gel (OsteoBiol 0, Tecnoss) and a collagenated porcine bone (OsteoBiol Gen Os, Tecnoss) as a grafting material in combination with a bone cortical lamina (OsteoBiol Lamina Cortical Soft Tecnoss) can lead to the

augmentation of the alveolar crest or the maxillary sinus floor prior to or in conjunction with implant place-ment (Pagliani and Volpe 2010). Histology revealed new bone formation at porcine bone surface, which formed bridges between particles and between particles and preexisting bone. The presence of scalloped

BioOss

a

PepGen P-15

b

OsteoBiol

c

Biocoral

d

Fig. 2.11 Morphology of the commercial granular samples: (a) Bio-Oss®, (b) PepGen P-15®, (c) OsteoBiol® and (d) Biocoral®. The SEM images show different shapes and structural features

for various particulate materials (Figueiredo et al. 2010) (Reprinted with permission from John Wiley & Sons)


resorption lacunae and new osteons inside the particles indicated ongoing resorption/remodeling of the parti-cles. The histomorphometric analyses showed that the total specimen area consisted of, in average, 56.5 ±15.7% of mineralized tissue of which 24.8 ± 13.9% of the total area was porcine bone particles. Similar data were reported also by Nannmark and Sennerby (2008) who evaluated the response of the bone tissue to prehy-drated and collagenated porcine bone, with or without a collagen gel, covered with a collagen membrane (OsteoBiol Evolution, Tecnoss). The histological exam-inations, performed after 8 weeks, showed an active reabsorption of the materials, by osteoclasts as well as part of remodeling with the formation of osteons within the particles, the presence of mature bone and vascular-ization of the mineralized part and of the soft tissue, and, finally, the active degradation of the collagen in an animal model. Different collagen/collagenated porcine bone ratios do not influence the bone tissue responses to collagenated porcine bone. Both materials exhibited osteoconductive properties and were starting to be resorbed at 8 weeks (Nannmark and Azarmehr 2010). No studies are presently available for the treatment of periodontal bony defects.

2.3.3 Coralline Calcium Carbonate

Natural coral graft substitutes are derived from the exoskeleton of marine madreporic corals. Researchers first started evaluating corals as potential bone graft substitutes in the early 1970s in animals and in 1979 in humans. The structure of the commonly used coral, Porites, is similar to that of cancellous bone, and its initial mechanical properties resemble those of bone. Polyps absorb the calcium ions and carbonic acid present in the seawater to produce aragonite crystals of calcium carbonate, representing 97–99% of the coral exoskeleton. The remaining balance is made up from various elements, such as oligoelements com-prising 0.5–1%, magnesium varying from 0.05% to 0.2%, sodium in quantities of 0.4–0.5%, amino acids representing 0.07% and the remainder consisting of traces of potassium (0.02–0.03%), strontium, fluorine and phosphorous in the phosphate form. The oligoele-ments found in coral are known to play a critical role in the bone mineralization process and in the activa-tion of enzymatic reactions with osteoid cells. Strontium contributes to the mineralization process

and protects calcification. Fluorine, present 1.25–2.5 times more in coral than in bone, helps bone formation through its effects on osteoblast proliferation. The main differences between natural coral and bone include the organic content and the mineral composi-tion. One third of the total weight in bone is composed of organic components, while the coral organic con-tent is limited to 1–1.5%. The mineral composition of bone is mainly hydroxyapatite and amorphous cal-cium phosphate associated with calcium carbonate, while coral is essentially calcium carbonate (Demers et al. 2002).

Biocoral (Inoteb, Saint Gonnery, France) is a com-mercially available product.

Biocoral is a resorbable bone graft substitute that belongs to the Porites group and had an architecture very similar to that of spongy bone, with a poros-ity > 45% and interconnecting pores of diameter 100–200 mm (Mora and Ouhayoun 1995; Yukna 1994a). Coral-derived calcium carbonate constructs can be converted to hydroxyapatite by hydrothermal exchange (Ripamonti et al. 2009). The porosity, especially open porosity, of the material seems to influence the speed of colonization and the resorption rate (Piattelli et al. 1997). Quantitative results showed that the larger the porosity volume, the greater was the coral resorption as well as the new bone apposition (Guillemin et al. 1989). The concavities of the matrices biomimetize the remod-eling cycle of the osteonic primate corticocancellous bone and promote the ripple-like cascade of the induc-tion of bone formation (Ripamonti et al. 2009).

Biocoral particles had a very high osteoconductive potential because no fibrous encapsulation has been reported (Piattelli et al. 1997) (Fig. 2.12). Unlike porous hydroxyapatite, derived from the same coral by heat conversion and made non-resorbable, calcium carbonate is resorbable. When implanted into bone tissue, the cal-cium carbonate crystals gradually resorb to be replaced by mature bone; no fibrous tissue encapsulation, like that reported with hydroxyapatite, was seen (Kim et al. 1996; Piattelli et al. 1997; Gao et al. 1997; Ning et al. 2009). The degradation of Biocoral has been reported to be species specific: 100% degradation in a 3 -month period has been reported in a rabbit tibia model (Pollick et al. 1995), while in man most of the particles were present after a 6 -month period (Piattelli et al. 1997).

Porous hydroxyapatite (Interpore 200, Irvine, CA) is obtained by the hydrothermal conversion of the calcium carbonate exoskeleton of natural coral into calcium pho-sphate hydroxyapatite (Saad AlGhamdi et al. 2010b).

932.3 Xenografts

Meta-analysis performed by Trombelli et al. (2002) on four selected studies (Kim et al. 1996; Mora and Ouhayoun 1995; Schulz et al. 2000; Yukna 1994a) resulted in a statistically significant difference in CAL gain between coralline calcium carbonate and OFD (weighted mean difference 0.90 mm [95% CI: 0.53–1.27; Q-test for heterogeneity: 6.16 (df = 3), P = 0.10]. No significant improvement in probing depth

reduction was observed (weighted mean difference: 0.04 mm).

Reynolds et al. (2003) consistently reported a weighted mean difference in clinical attachment level gain of 0.91 ± 1.94 mm. When changes in bone level were considered, the analysis from three studies (Kim et al. 1996; Mora and Ouhayoun 1995; Yukna 1994a) suggested that coralline calcium carbonate produces a

Fig. 2.12 (a) Photo-micrograph of site implanted with the coral-derived biomaterial showing new bone (NB) and cementum (NC) formation in the notch area (N) (H–E, original magnification ×20). The higher magnifications show the oblique or perpendicular collagen fiber arrangement. (b) A thick layer of new cementum with an oblique or perpendicular collagen fiber arrangement (arrowheads) was observed in the notch area (H–E, original magnifi-cation ×100). (c) A well-organized periodontal ligament exhibiting a thinner new cementum layer was observed more coronally (H–E, original magnification ×200). (d) Newly formed osteoid tissue and bone with enclosed osteocytes were deposited around coral-derived biomaterial particles (R) (H–E original magnifica-tion ×200) (Kim et al. 2005) (Reprinted with permission from John Wiley & Sons)


significant (P = 0.001) and consistent (heterogeneity not significant) treatment effect (gain in bone fill: 2.21 ± 1.82 mm) (Reynolds et al. 2003). Similar with the previous meta-analysis, no significant improvement in probing depth reduction was noted when treatment with coralline calcium carbonate was compared with OFD (weighted mean difference: 0.09 mm).

Several studies suggested that a bioresorbable cal-cium carbonate coral implant significantly enhanced space provision for GTR, while alveolar bone forma-tion appeared to be enhanced by its use (Wikesjö et al. 2003; Koo et al. 2005; Polimeni et al. 2004).

2.4 Alloplasts (Alloplastic Synthetic Grafts)

An alloplast is a biocompatible, inorganic synthetic bone grafting material. At present, alloplasts marketed for periodontal regeneration fall into two broad classes: ceramics and polymers. The fate of an alloplastic bone grafting material is dependent primarily on its chemi-cal composition, structure and physical properties (Reynolds et al. 2010).

According to Ashman (1992), an ideal synthetic bone material should be:

1. Biocompatible 2. Able to serve as a framework for new bone

formation 3. Resorbable in the long term and have potential for

replacement by host bone 4. Osteogenic, or at least facilitate new bone

formation 5. Radiopaque 6. Easy to manipulate clinically 7. Not support the growth of oral pathogens 8. Hydrophilic 9. Available in particulate and molded forms 10. Have surface electrical activity (i.e., be charged

negatively) 11. Microporous and provide added strength to the

regenerating host bone matrix, and permit biologi-cal fixation

12. Readily available 13. Nonallergenic 14. Adapt to be effective in a broad range of medical

situations (e.g., cancer, trauma and infective bone-destroying diseases)

15. Have a surface that is amenable to grafting 16. Act as matrix or vehicle for other materials (e.g.,

bone protein inducers, antibiotics and steroids) 17. Have high compressive strength

2.4.1 Polymethylmethacrylate and Polyhydroxylethylmethacrylate (PMMA-PHEMA) Polymers

Polymers present some options that the other groups do not. Like many polymers are potential candidates for bone graft substitutes represent different physical, mechanical, and chemical properties. The polymers used today can be loosely divided into natural poly-mers and synthetic polymers. These, in turn, can be divided further into degradable and nondegradable types (Nandi et al. 2010).

At present, a biocompatible microporous polymer containing polymethylmethacrylate (PMMA), poly-hydroxylethylmethacrylate (PHEMA) and calcium hydroxide is available as a bone grafting material for the treatment of periodontal defects (HTRTM Synthetic Bone – Bioplant, Norwalk, CT). This composite is prepared from a core of PMMA and PHEMA with a coating of calcium hydroxide (Reynolds et al. 2010). It forms calcium carbonate apatite when introduced into the body and interfaces with bleeding marrow (Gross 1997).

The properties of PMMA-PHEMA polymer include a marked hydrophobicity that facilitates hemostasis, extensive microporosity (150–350 mm interled pore size, which results in a 20–30% material porosity), biocompatibility, an important compressive strength (50,000–60,000 psi) and a negative surface charge (−8 to −10 mV), which is believed to impede develop-ment of infection (Ashman 1988). The polymer is hydrophilic and osteophilic, which purportedly aids in stabilization of the healing clot (Reynolds et al. 2010). Its hydrophilicity enhances clotting, and its negative particle surface charge allows adherence to bone. It appears to serve as a scaffold for bone formation when in close contact with alveolar bone (Nasr et al. 1999). PMMA-PHEMA polymer does not produce an inflam-matory or immune response after prolonged contact with bone or soft tissue (Ashman and Moss 1977).

Histological evidence of new bone formation on PMMA-PHEMA particles has been reported (Stahl


et al. 1990; Froum 1996; Al Ruhaimi 2001; Haris et al. 1998). Histologic responses varied from gain in clo-sure by epithelial adhesion to new attachment of vary-ing magnitude. At the periphery of some particles, limited bone formation was present. The alveolar bed was remodeling, at times surrounding specific particles (Stahl et al. 1990). Froum (1996) showed that PMMA-PHEMA particles were present and surrounded by connective tissue or bone. PMMA-PHEMA appears to serve as a scaffold for new bone formation when in close contact with alveolar bone.

More clinical studies have provided evidence for the effectiveness of this polymeric grafting material in improving clinical parameters in the treatment of fur-cations and intrabony defects parameters, relative to open flap debridement (Shahmiri et al. 1992; Yukna 1990, 1994b; Yukna 1994b; Yukna and Yukna 1997; Yukna and Greer 1992; Calongne et al. 2001; Prakash et al. 2010).

In a systematic review (Trombelli et al. 2002), a clini-cal attachment level gain of 1.9 ± 1.1 mm in the test group, PMMA-PHEMA, and 1.0 ± 0.9 mm in the control group, open flap debridement, was found. The differ-ence between treatments (0.90 mm, SE 0.22) was statis-tically significant (P < 0.001) (Trombelli et al. 2005).

2.4.2 Demineralized Dentin Matrix (DDM)

The organic component of dentin, which accounts for approximately 20% of dentin weight, is mainly type I collagen, a component of bone. Dentin also contains bone morphogenetic proteins (BMPs), which promote the differentiation of mesenchymal stem cells into chondrocytes, and thus enhance bone formation, non-collagen proteins such as osteocalcin and osteonectin, which have been implicated in calcification and dentin-specific proteins including dentin phosphopro-tein, also known as phosphophoryn, and dentin sialo-protein (Yagihashi et al. 2009; Kawai and Urist 1989; Feng et al. 1998; Ritchie et al. 1998).

Studies of various mammalian demineralized den-tins have shown to be biocompatible, are able to induce differentiation of undifferentiated mesenchymal cells into osteogenic cells, and thus bone and cartilage for-mation, and are resorbed during the bone remodeling process (Reddi and Huggins 1973; Inoue et al. 1986a, 1986b; Ihoki 1991; Muramatsu et al. 1993; Beertsen et al. 1993; Ymane et al. 1998; Gomes et al. 2001;

Carvalho et al. 2004; Machado et al. 2006; Yagihashi et al. 2009).

Only one study evaluated the effect of implants of allogenic demineralized dentin on bone regeneration and healing in the treatment of infrabony periodontal defects (Movin et al. 1982). The defects were classified as two-wall and combined three- and two-wall bony defects. During healing, no clinical signs of rejection of the dentin implants were observed, but the soft tissue healing was delayed, probably due to a slow resorption of the dentin implants. No conclusive evidence regarding the capacity of allogenic demineralized dentin to induce new connective tissue attachment could be drawn.

2.4.3 Hydroxylapatite (HA)

Synthetic hydroxyapatite, Ca10

(PO4)

6(OH)

2, has been

available for more than 30 years. It is the primary min-eral found in bone. Synthetic hydroxyapatite can be found as porous or nonporous and in ceramic or non-ceramic forms (Kuo et al. 2007).

HAs present remarkable biocompatibility with little inflammatory response when implanted within con-nective and bone tissues (Froum et al. 1982; Beckham et al. 1971; Jarcho et al. 1977; de Putter et al. 1983). Histologic studies (Froum et al. 1982; Sapkos 1986; Stahl and Froum 1987) demonstrated that healing often occurred with encapsulation of HA graft materials in connective tissue with no indication of new periodon-tal attachment, osteogenesis or cementogenesis, in the host tissues adjacent to the graft particles. Healing was characterized primarily by formation of a long junc-tional epithelium. The graft material therefore acted as a biocompatible foreign body within the gingival tissue (Fig. 2.13).

The advantages of using hydroxyapatite are: (1) immunoreaction can be ignored; (2) postoperative mor-phologic changes and volume decreases do not occur if small blocks and chips are adequately packed during surgery; (3) postoperative adsorption of hydroxyapa-tite, if any, is slight and slow and is replaced by bone; and (4) cement fixation performed on a layer of hydroxyapatite particles prevents the harmful influence of polyethylene wear particles of cement interface. The clinical disadvantages hydroxyapatite particles are that they tend not to stay in place in a bleeding site, and there is a relatively slow restoration of bone within the assemblage of particles (Oonishi et al. 1997).


Meta-analysis of controlled clinical studies (Galgut et al. 1992; Kenney et al. 1985; Mora and Ouhayoun 1995, Yukna et al. 1998) performed by Trombelli et al. (2002) reported that various forms of HA (porous/non-porous) resulted in significantly greater attachment gain with respect to conventional open flap debride-ment (OFD) alone (weighted mean difference 1.40 mm, 95% CI: 0.64–2.16). However, meta-analysis revealed that there was highly significant evidence of heteroge-neity among studies (Q-test for heterogeneity: 10.72 (df = 3), P = 0.01). Meta-analysis showed also that hydroxyapatite resulted in significantly greater prob-ing depth reduction than the OFD procedure (weighted mean difference 0.98 mm, 95% CI: 0.67–1.29).

The meta-analysis of Reynolds et al. (2003) revealed also the beneficial effect of HA treatment compared with the OFD relative to clinical attachment level gain (1.20 ± 2.22 mm) and probing depth reduction (1.58 ± 1.77 mm), the difference being statistically significant.

Similar positive clinical results were reported when HA grafts were compared to osseous allografts in human vertical lesions. Bowen et al. (1989) reported no significant difference in any of the soft tissue mea-surements when decalcified freeze-dried bone (DFDBA) and HA were compared. However, both treatment modalities reduced pocket depth and demonstrated a gain in clinical attachment levels. There was 2.2 mm of bone repair with DFDBA and 2.1 mm with HA. These values corresponded to a percent defect fill of 61% for DFDBA and 53% for HA. These values were likewise not statistically different (Bowen et al. 1989). In contrast, Oreamuno et al. (1990) indicated that more clinical resolution of interproximal periodontal defects in humans can be obtained with the use of porous HA than with the use of DFDB.

However, the data and clinical findings suggested that FDBA may have some enhanced reparative poten-tial when compared to granular porous HA in the treat-ment of periodontal defects in humans. Results showed a mean osseous fill of 2.1 mm for FDBA versus 1.3 mm for granular porous hydroxylapatite (P = 0.07). A mean clinical attachment gain of 2.2 mm for FDBA versus 1.3 mm for granular porous hydroxylapatite (P < 0.05), and a mean decrease in probing depths of 3.0 mm for FDBA versus 1.4 mm for granular porous hydroxy-lapatite (P < 0.5) was found. FDBA was clinically indistinguishable from host bone, whereas porous hydroxylapatite appeared to be separated from host bone by soft tissue (Barnett et al. 1989).

No significant difference in the use of natural coral skeleton or porous hydroxyapatite for treating 1, 2 wall or combined periodontal bone defects for the clinical parameters was reported (clinical probing depth, clini-cal attachment, gingival recession, bone fill, % bone fill and crest remodeling). Beneficial effects of using each of the biomaterials were revealed (57.4% for nat-ural coral skeleton, 58.1% for porous hydroxyapatite, P < 0.86) as opposed to simple debridement (22.2%; P < 0.002; P < 0.004) (Mora and Ouhayoun 1995).

There are several available forms of hydroxy-lapatite:

1. The polycrystalline ceramic form of pure densely sin-tered HA is non-resorbable, osteoconductive, has a low microporosity and act primarily as inert biocom-patible fillers (Aichelmann-Reidy and Yukna 1998) (Fig. 2.14). It is prepared in relatively large particle size (18–40 mesh) in most commercially available alloplastic preparations: Calcitite (20–40 Mesh (420–840 mm) and 40–60 Mesh (250–420 mm)) (Calcitek,

Fig. 2.13 Light micrograph demonstrating fibrous encapsula-tion of an alloplastic bone-substitute material (asterisks). There is no new bone formation at all (paraffin section stained with hematoxylin and eosin) (Bosshardt and Sculean 2009) (Reprinted with permission from John Wiley & Sons)


Fig. 2.14 Scanning electronic microscopical observation of an osteoinductive HA ceramic (S-HA) and a non-osteoinductive HA ceramic (J-HA). Note the micropores in osteoinductive HA and the absence of micropores (the dense wall) in non-osteoin-ductive HA (c) magnification of the square in (a); (e) magnifica-tion of the square in (c); (d) magnification of the square in (b); (f) magnification of the square in (d). As described by the pro-ducer, S-HA: Hydroxyapatite ceramic rods, ∅5 × 6 mm, average

pore size 400 mm, porosity 60–70%, sintered at 1,100°C, pre-pared by Sichuan Union University (gdu, China); J-HA: Hydroxyapatite ceramic rods, ø3.5 × 8.5 mm, provided by Mitsubishi Ceramic Int. (Japan), had a average pore size of 200 mm, a porosity of 70%, and was sintered at 1,200°C (Yuan et al. 1999; Yuan and De Groot 2004) (Reprinted with permis-sion from Elsevier)


Inc., Carlbad, CA), OsteoGraf/D300 (particle size 250–420 mm) or OsteoGraf/D700 (particle size 420–1,000 mm) (CeraMed Corp., Lakewood, CO).

2. The coralline porous non-resorbable hydroxylapa-tite is a replica of a marine coral skeleton, Porites. After the organic components of the coral have been removed, the aragonite of the coral skeleton is con-verted to HA by treatment with an ammonium phosphate at elevated temperature and pressure. This hydroxylapatite is formed as small crystals in contrast with the large fused crystals found in the sintered or ceramic-like forms of artificial HA (Kenney et al. 1985).

Human histological studies have revealed ossifica-tion in the pores of the hydroxylapatite, along their internal lining with bands of bone varying in width from 20 to 150 mm (Carranza et al. 1987). The ossifi-cation of the implant pores and the implant periphery as early as 3 months after implantation became pro-nounced 12 months after placement (Stahl and Froum 1987). These findings provide evidence that the porous HA has the ability to facilitate osteogenesis within the porous structure of the implant when placed in human periodontal defects (Kenney et al. 1986).

It is marketed in different trade names like Inter-pore 200 (Interpore International, Irvine, CA) and Pro-Osteon 500R (Interpore Cross International, Irvine, CA, USA).

3. The resorbable nonceramic hydroxylapatite is highly microporous, non-sintered (nonceramic), composed of small particles measuring 300–400 mm (35–60 mesh), with a controlled, predictable rate of resorption. As the material resorbs, it acts as a min-eral reservoir and predictably induces new bone formation via osteoconductive mechanisms. The material appears to be very biocompatible in both hard and soft tissues (Wagner 1989).

It is marketed in different trade names like Oste-ogen® (Impladent, NY, USA), OsteoGraf/LD-300 (particles are sized between 250 and 420 mm) (Cera-Med Corp., Lakewood, CO) and Cerabone® (Cori-pharm GmbH & Co. KG, Dieburg, Germany).

4. Nanocrystalline hydroxyapatite (NHA). Researchers have found that nanoparticular hydroxyapatite not only provides the benefits of traditional hydroxy-apatites, but also resorbs (Kuo et al. 2007).

Preliminary experimental studies have shown that nanosized ceramics may represent a promising class of bone graft substitutes due to their improved osseointegrative properties and complete resorption

of the material within 12 weeks, being resorbed by osteoclasts (Thorwarth et al. 2005; Chris Arts et al. 2006; Laschke et al. 2007). NHA exhibited good biocompatibility comparable to that of cancellous bone, as indicated by a lack of venular leukocyte activation after implantation (Laschke et al. 2007) and can promote proliferation and osteogenic dif-ferentiation of periodontal ligament cells (Kasaj et al. 2008a; Sun et al. 2007). Biopsy specimens taken at different time intervals from human patients with various types of fractures revealed that the studied nanocrystalline hydroxyapatite paste showed good tissue incorporation and bone regeneration: well-structured cortical and cancel-lous bone tissue with focal fibrosis of the medullary space. Bone healing and ramifications of trabecular bone could be seen between the implant particles. In all specimens, new bone formation was clearly visible beginning with the deposition of osteoid directly onto the substitute material and second-ary mineralization in the presence of cell layers resembling osteoblasts (Huber et al. 2006; Huber et al. 2008). Histological studies of intraosseous periodontal defects treated with NHA revealed, after 7 months, an almost complete resorption of the graft. The healing was characterized by the for-mation of new connective tissue or long epithelial attachment. New cementum and new bone varied from 0 to 0.86 mm and from 0 to 1.33 mm, respec-tively (Horvath et al. 2009).

A ready-to-use paste in a syringe, available under the name Ostim™ (Heraeus Kulzer, Hanau, Germany) (NHA), synthetic nanocrystalline hydroxyapatite (NHA) paste containing 65% water and 35% nano-structured apatite particles has been recently intro-duced in the market. Advantages of this material are the close contact with surrounding tissues, quick resorption characteristics and the large number of molecules on the surface (Schwarz et al. 2006a; Kasaj et al. 2008a) (Fig. 2.15). The needle-shaped HA crystals form agglomerates in transmission electron microscopy (Fig. 2.16). The average crystallite size is 100 nm/20 nm/3 nm, the atomic ratio of calcium phosphorus is 1.67. Ostim paste does not harden after application into the bone and is free of endo-thermical heating. It is characterized by a large bio-active specific surface area of 106 m2/g. The Ostim syringe in the double-sterile pack can be used to apply paste to the bone defect directly or by means of applicators (Huber et al. 2006).


Fig. 2.15 The use of a bioresorbable nanocrystalline hydroxy-apatite paste in acetabular bone impaction grafting. Histology results: (a) Section of an empty defect after 8 weeks. The defect borders are denoted by the circle (+ represents 5.5 mm). (b) New bone formation (NB) on a bone graft remnant (BG) with osteo-blasts lining the bone graft (arrows) (c) Areas of non-resorbed

Ostim (O) integrated in new bone (NB). (d) Osteoclasts (arrows) against islands of Ostim (O). (e) TRAP staining confirmed the presence of osteoclasts (arrows) on Ostim (O). (f) New bone (NB) osseous-integrated with Ostim (O) and TCP-HA granules (BS). Bar scale B–F 0.1 mm (Chris Arts et al. 2006) (Reprinted with permission from Elsevier)


a b

Fig. 2.16 SEM image of Ostim® (a) and REM image of Cerabone® (b). Ostim is a viscous paste, which contains phase pure nanosize hydroxyapatite crystals as a suspension in water (a). In contrast, the granules of Cerabone are synthesized of a

solid hydroxyapatite ceramic (pentacalcium hydroxide triphos-phate) with a pore size of ~0.1–1.5 mm (b). Scale bars: A = 250 mm; B = 350 mm (Laschke et al. 2007) (Reprinted with permission from John Wiley & Sons)

Fig. 2.17 (a) Semi-circumferential intrabony defect. (b) Situation following application of nanocrystalline hydroxyapa-tite. (c) Situation following application of bovine-derived xenograft in the circumferen-tial bone defect. Bio-Gide collagen membrane was trimmed and adapted over the oral and (d) the vestibular aspect of the defect (Schwarz et al. 2006a) (Reprinted with permission from John Wiley & Sons)


The NHA has been proven to be useful for aug-mentation procedures in osseous defects (Moghadam et al. 2004; Thorwarth et al. 2005) (Fig. 2.17), in the peri-implantitis lesions (Schwarz et al. 2006a; Schwarz et al. 2008; Schwarz et al. 2009) and intraosseous periodontal defects (Fig. 2.18) (Kasaj et al. 2008a; Horvath et al. 2009; Heinz et al. 2010). After 6 months, the treatment of intrabony periodon-tal defects with an NHA paste led to significantly improved clinical outcomes when compared with open flap debridement alone. Kasaj et al. (2008a) reported a reduction in mean PD from 7.4 ± 1.3 mm to 3.4 ± 1.2 mm and a change in mean CAL from 8.0 ± 1.3 mm to 4.4 ± 1.7 mm for the test group, whereas in the control group the mean PD decreased

from 7.4 ± 0.8 mm to 4.9 ± 0.9 mm, and mean CAL decreased from 8.1 ± 1.2 mm to 6.4 ± 1.3 mm. Similar results were reported by Heinz et al. (2010) who showed that the sites treated with NHA paste showed a reduction in mean PPD from 8.3 ± 1.2 to 4.0 ± 1.1 mm and a gain in PBL of 4.3 ± 1.4 mm, whereas in the control group, the mean PPD changed from 7.9 ± 1.2 mm to 5.0 ± 1.2 mm and PBL gain was 2.6 ± 1.4 mm. Horvarth et al. (2009) reported a PD reduction of 4.0 ± 0.9 mm and a CAL gain of 2.5 ± 0.8 mm, on average after the NHA treatment.

5. Fluorohydroxyapatitic (FHA) biomaterial. The natural architecture of some calcified algae offers a surface that is similar to that of bone (Kasperk et al. 1988) Damien and Revell 2004.

a b

c d e

Fig. 2.18 Surgical treatment of intrabony periodontal defects with a fully synthetic nanocrystalline hydroxyapatite (nano-HA) paste (Ostim®; Heraeus Kulzer, Hanau, Germany) containing 65% water and 35% of nanostructured apatite. (a) The intraop-erative clinical image shows a deep intrabony defect distal of the

lower right first premolar. (b) Nano-HA paste placed. (c) Clinical situation 6-month postoperative. (d) Presurgical radiograph. (e) 6-month postoperative radiograph (Heinz et al. 2010) (Reprinted with permission from Springer)


The commercially available porous biomaterial FRIOS® Algipore® (Friadent GmbH, Mannheim, Germany) is manufactured from calcifying marine algae (Corallina officinalis). The particles con-tain a pore system with a mean diameter of 10 mm that is periodically septated (mean interval 30 mm) and interconnectively microperforated (mean diameter of perforations 1 mm). Every pore is lim-ited by one layer of small FHA crystallites with a size of 25–35 nm (Fig. 2.19). The impression of a bilayer texture of the walls arises by the contact of the layers of adjacent pores (Schopper et al. 2003). This material is biocompatible, osteocon-ductive and has an additional desirable property of being slowly resorbable and replaced by newly formed bone (Ricci et al. 1992; Schopper et al. 2003; Ewers et al. 2004; Klongnoi et al. 2006). Clinical investigations demonstrated good results in sinus augmentation (Ricci et al. 1992; Schopper et al. 2003; Klongnoi et al. 2006; Lee et al. 2009). In an animal model, they suggest that C-Graft particles provide a scaffold for the regeneration of new bone and cementum in periodontal bone defects in dog (Nakanishi et al. 2009).

Biostite® (Vebas s.r.l., S. Giuliano Milanese, Italy) is a mixture of synthetic HA (88.0%, granu-lometry of 160–200 mm, total porosity of 60%), equine type I collagen (9.5%) and chondroitin sul-fate (2.5%). Chemically, Biostites particles demon-strated a major phase represented by polycrystalline synthetic HA (³99%), little presence of b-tricalcium phosphate and CaO (£1%) and a Ca–P ratio ranging from 1.665 to 1.697 (Scabbia and Trombelli 2004). The material has proved to be highly biocompatible and osteoconductive (Benqué et al. 1985; Serre et al. 1993), as well as actively reabsorbable (Parodi et al. 1996). It has been shown that Biostite®, may directly affect osteoblasts by enhancing chondro/osteogenic gene expression and cytoskeleton-related signaling pathways, which may contribute to its clinical efficacy (Sibilla et al. 2006). Clinical studies have shown favorable effects of Biostite® in improv-ing attachment and probing depth when used for the treatment of intraosseous defects, similar with those obtained with an anorganic xenograft (Bio-Oss®, Geistlich Pharma AG, Wolhusen, Switzerland) (Scabbia and Trombelli 2004).

Biphasic alloplastic materials produced by sintering hydroxyapatite (HA) and tricalcium

a

b

c

Fig. 2.19 (a) Scanning electronmicroscopic examination visu-alizes the spatial arrangement of the pore system within the fluo-rohydroxyapatite (FHA) FRIOS Algipore biomaterial particles. Arrows show the periodical septation of the pores. (b) Microperforations (arrows) within the fragile walls of the pores connect adjacent pores with each other. (c) Small FHA crystal-lites are assembled within the walls of the pores. Every pore is limited by one FHA layer. The impression of a bilayer texture of the walls (arrows) arises by the contact of the layers of adjacent pores. (a) Bar = 100 mm. (b, c) Bar = 10 mm (Schopper et al. 2003) (Reprinted with permission from John Wiley & Sons)


Ca/P molar ratio Compound Formula Symbol

0.5 Monocalcium phosphate monohydrate Ca(H2PO

4)

2 · H2O MCPM

0.5 Monocalcium phosphate anhydrous Ca(H2PO

4)

2MCPA

1.0 Dicalcium phosphate dihydrate CaHPO4 · 2H

2O DCPD

1.0 Dicalcium phosphate anhydrous CaHPO4

DCPA

1.33 Octacalcium phosphate Ca8(HPO

4)

2(PO

4)

4 · 5H

2O OCP

1.5 a-Tricalcium phosphate a-Ca3(PO

4)

2a-TCP

1.5 b-Tricalcium phosphate b-Ca3(PO

4)

2b-TCP

1.67 Hydroxyapatite Ca10

(PO4)

6(OH)

2HA

2.0 Tetracalcium phosphate Ca4(PO

4)

2O TTCP or TetCP

Table 2.4 Main calcium phosphate compounds

Source: Kamitakahara et al. (2008). Reprinted with permission from Sage Publications

phosphate include Calcitec® Inc. (Austin, TX), Osteogen® (Impladent Ltd, Holliswood, NY), Tricos® (Baxter, Bern, Switzerland), MBCP (Biomatlante, Vigneux de Bretagne, France), Ceraform® (Teknimed SA, Vic-en Bigorre, France) and Bone Ceramic® (Straumann, Basel, Switzerland).

2.4.4 Calcium Phosphate Cement (CPC)

Among the materials used for bone and tissue regen-eration, calcium phosphate cements are gaining spe-cial interest due to their biomimetic nature and potential use as controlled release systems (Table 2.4). These cements are prepared by mixing a liquid phase with a solid phase to create a workable paste that sets into a solid material (Ambard and Mueninghoff 2006; Tamimi et al. 2008; Burguera et al. 2008). The inject-able CPC required minimal manipulation to fill and mold the defect wall compared to the placement of a membrane with the GTR procedure (Shirakata et al. 2007). Unfortunately, CPCs have been reported to suf-fer from some problems, such as prolonged setting time and the inability to set in the presence of blood. Recently, new improved cements have been developed, especially suited for the filling of peri-implant and periodontal defects. They are reported to have a short setting time (around 10 min), fast biodegradation and the possibility to be applied with a syringe (Comuzzi et al. 2002). Premixed calcium phosphate cements were also developed (Xu et al. 2007).

The histological and histomorphometrical exami-nations confirmed the excellent bone biocompatibility

and osteoconductive properties of the used CaP cement. The material did not evoke any inflammatory response, but favored new bone formation comparable with autologous bone grafting (Aral et al. 2008; Yuan et al. 2000) (Fig. 2.20). This material had been used as a bioabsorbable barrier for guided tissue regeneration in periodontal defects (AlGhamdi et al. 2010b). Animal models revealed that CPC have a high biocompatibil-ity and has an ability to act as a stable scaffold for bone formation and provide adequate space for periodontal tissue regeneration (Fujikawa et al. 1995; Shirakata et al. 2002; Hayashi et al. 2006; Shirakata et al. 2007; Sugawara et al. 2008; Lee et al. 2010). Moreover, in vivo, it cures into an osteoconductive carbonated apatite with chemical and physical characteristics sim-ilar to the mineral phase of bone, which subsequently is replaced by natural bone (Shirakata et al. 2008; Constantz et al. 1995; Cohen and Whitman 1997; Elder et al. 2000). Resorption of calcium phosphate ceramics occurs by dissolution or is cell mediated, for example, by foreign body giant cells and osteoclasts (Aral et al. 2008; Yuan et al. 2000). Fast resorption of residual material is desirable to avoid the risk for infection and increase the amount of regenerated periodontal tissue. In line with this, histologic results indicated that when holes were drilled into the hardened CPC, resorption of the CPC mass improved, supposedly by increasing the surface area of the material and allowing increased vascular supply (Shirakata et al. 2002). Experimental studies have proposed the CPCs as a suitable graft for repairing root perforations (Noetzel et al. 2006), sinus augmentation (Aral et al. 2008), as a filler for bone defects around oral implants (Comuzzi et al. 2002) and in alveolar ridge augmentation (Sato et al. 2009).


a b

Fig. 2.20 Osteoconductive effects of calcium phosphate glass cement grafts in rabbit calvarial defects. Surgical sections from the calcium phosphate glass cement (CPGC) group. (a) Histologic view of the CPGC group. Most particles were resorbed and new bone was formed above the notch (H–E, ×20; base of reference notch [bN]: arrow; height of new bone: black diamond; CPGC

particle: black star; bar = 2 mm). (b) Histologic view of magni-fied black square area (×200). Osteoblast-like cells were observed around remaining particles. Peripheral new bone was woven bone with isolated osteocytes (H–E, ×200; CPGC particle: black star; NB: new bone; WB: woven bone; bar = 0.1 mm) (Lim et al. 2010) (Reprinted with permission from John Wiley & Sons)

When CPC was used in human studies for peri-odontal bone repair, tooth mobility resulted in early fracture and eventual exfoliation of the rigid and brit-tle implants (Brown et al. 1998; Xu et al. 2002). Controversial results were obtained from clinical studies, CPCs being either significantly better than hydroxyapatite ceramic granules (Rajesh et al. 2009) either failing to demonstrate any superior clinical outcomes for the CPC compared to the OFD when used in treating intraosseous periodontal defects (Shirakata et al. 2008). Recently, Mellonig et al. (2010) evaluated the clinical and histologic results of a calcium phosphate bone cement in the treatment of human periodontal intraosseous defects. At 6 months, results demonstrated that all defects resulted in prob-ing depth reduction and in clinical attachment level

gain. However, no site showed periodontal regenera-tion and there was no new bone formation. New cementum and connective tissue were limited to 0.2 mm or less. Large deposits of the bone cement were noted encapsulated in connective tissue (Mellonig et al. 2010).

In recent years, lots of phosphate cements have been developed and studied (Table 2.5). Common components besides tetracalcium phosphate, dical-cium phosphate dihydrate or anhydrous are monocal-cium phosphate monohydrate and anhydrous, octacalcium phosphate, tricalcium phosphate, hydroxyapatite and fluorapatite, with different addi-tives like carbonates, sulfates or metallic oxides. Water, calcium- or phosphate-containing solutions, organic acids or aqueous solutions of polymers are


Table 2.5 List of commercial calcium phosphate cements with their composition (when available)

Company Cement name Components End-product

ETEX a-BSM Powder: ACP (50%), DCPD (50%) Apatite

Embarc Solution: H2O (unbuffered saline solution)

Biobon

Stryker-Leibinger Corp.

BoneSource Powder: TetCP (73%), DCP (27%) Apatite

Solution: H2O, mixture of Na

2HPO

4 and NaH

2PO

4

Teknimed Cementek® Powder: a-TCP, TetCP, Na Glycerophosphate Apatite

Solution: H2O, Ca(OH)

2, H

3PO

4

Cementek® LV Powder: a-TCP, TetCP, Na Glycerophosphate, dimethylsiloxane

Apatite

Solution: H2O, Ca(OH)

2, H

3PO

4

Biomet Calcibon® (previously called “Biocement D”)

Powder: a-TCP (61%), DCP (26%), CaCO3 (10%),

PHA (3%)Apatite

Solution: H2O, Na

2HPO

4

MimixTM Powder: TetCP, a-TCP, C6H

5O

7Na

3 · 2H

2O Apatite

Solution: H2O, C

6H

8O

7

QuickSet MimixTM Powder: nfa Solution: nfa

Apatite

Mitsubishi Materials Biopex® Powder: a-TCP (75%), TetCP (20–18%), DCPD (5%), HA (0–2%)

Apatite

Solution: H2O, sodium succinate (12–13%),

sodium chondroitinsulphate (5–5.4%)

Biopex®-R Powder: a-TCP, TetCP, DCPD, HA, Mg

3(PO

4)

2, NaHSO

3

Apatite

Solution: H2O, sodium succinate, sodium

chondroitin sulphate

Kyphon KyphOsTM Powder: a-TCP (77%), Mg3(PO

4)

2 (14%),

MgHPO4 (4.8%), SrCO

3 (3.6%)

Apatite

Solution: H2O, (NH

4)

2HPO

4 (3.5 M)

Skeletal Kinetics CallosTM Powder: nfa Apatite

Solution: nfa

Shanghai Rebone Biomaterials Co, Ltd

Rebone Powder: TetCP, DCP Apatite

Solution: H2Ob

Synthes-Norian Norian® SRS Powder: a-TCP (85%), CaCO3 (12%) MCPM

(3%)Apatite

Norian® CRS Solution: H2O, Na

2HPO

4c

Norian® SRS Fast Set Putty Powder: nfa Apatite

Norian® CRS Fast Set Putty Solution: nfa

chronOSTM

chronOSTM InjectInject Powder: b-TCP (73%), MCPM (21%), MgHPO4 · 3H

2O (5%), MgSO

4 (o1%), Na

2H

2P

2O

7

(<1%)

Brushite

Solution: H2O, sodium hyaluronate (0.5%)

(continued)


used as cement liquids. The primary role of the liquid is to provide a vehicle for the dissolution of the reac-tants and precipitation of the products, although it may sometimes contain a reactant for the cement setting reactions (Noetzel et al. 2006). A nonrigid and high-strength CPC by incorporating tetracalcium phosphate and chitosan, a natural elastomeric and biocompatible biopolymer, into the conventional CPC was developed (Xu et al. 2002; Xu et al. 2006). The powder of Augmentech AT (Wetzlar, Germany) consists of trical-cium phosphate (TCP), magnesium phosphate, mag-nesium hydrogen phosphate and strontium carbonate. The liquid is a watery solution of diammonium hydro-gen phosphate (Noetzel et al. 2006). Norian® PDC™ (Shofu Inc., Kyoto, Japan) is injectable, moldable, fast setting, bioabsorbable and has high compressive strength. It is composed by a powder mix composed of a-tricalcium phosphate (a Ca

3[PO

4]

2), monocalcium

phosphate monohydrate (Ca[H2PO

4]

2 · H

2O) and cal-

cium carbonate (CaCO3) mixed with a solution of

sodium phosphate. It began to harden at a physiologic temperature and pH, and the final compressive strength was 55 MPa (compared to 1.9 MPa for cancellous bone). Its pore diameter was 300 Å. The powder and liquid are added separately in a sterile capsule and need to be blended inside the capsule using an amal-gam mixer-like apparatus for 20 s. The mixed CPC should be injected into the defects within 5 min (Shirakata et al. 2008). Norian PDC is bioabsorbable and is provided as a capsule composed of powder and liquid. Once the paste sets, it is moldable and inject-able within 5 min. Hardened Norian PDC has enough

compressive mechanical strength to be kept in the defect by itself without the use of a membrane. After solidification, the CPC can act as an occlusive space maintainer, providing adequate space for bone regen-eration (Sato et al. 2009).

The fabrication of CPC is a versatile process which yields a variety of tailor-made injectable pastes and sets cement materials with different physicochemical and mechanical properties. The ultimate properties of the cement will depend on the characteristics of the solid and aqueous phase and the reaction condi-tions. One feature of special interest in cements is the fact that they are intrinsically porous. They have an important percentage of porosity within the nano-/submicron size range. While porosity can be a limita-tion for the use of these materials in high-load-bear-ing applications, for example, vertebroplasty, it is vital for other applications. Porosity is sought to enhance a material’s resorbability and the extent of bioactivity by increasing the surface area available for reaction. In the same way, their inherent porosity makes these materials good carriers for controlled drug delivery systems (Espanol et al. 2009; Ginebra et al. 2006a, b).

The possibility to use CPCs not only as bone substi-tutes but also as carriers for local and controlled supply of drugs is very attractive and can be useful in treat-ments of different skeletal diseases, such as bone tumors, osteoporosis or osteomyelitis, which normally require long and painful therapies. Unlike calcium phosphate ceramics employed as drug delivery sys-tems, where the drugs are usually absorbed on

Source: Bohner et al. (2005) (and references therein). Reprinted with permission from ElsevierThe end product of the reaction can be either an apatite (calcium deficient, carbonated, etc.) or brushiteaNot found in the literature or on the webbAssumed composition based on the scientific literaturecEstimated compositiondThe cement consists of two liquids in which the various powder components are dispersed

Table 2.5 (continued)

Company Cement name Components End-product

Kasios Eurobone® Powder: b-TCP (98%), Na4P

2O

7 (2%) Brushite

Solution: H2O, H

3PO

4 (3.0 M), H

2SO

4 (0.1 M)

CalciphOs VitalOs Component 1: b-TCP (1.34 g), Na2H

2P

2O

7

(0.025 g), H2O, salts (0.05 M pH 7.4 PBS solution)

Brushite

Component 2: MCPM (0.78 g), CaSO4 · 2H

2O

(0.39 g), H2O, H

3PO

4 (0.05 M)


the surface, in CPCs the drugs can be incorporated throughout the whole material volume, by adding them into one of the two cement phases (Fig. 2.21). This fact can facilitate the release of drugs for more prolonged times (Ginebra et al. 2006a).

The studies about incorporation of drugs into CPC cover different aspects. In the first place, it is necessary to verify that the addition of the drug (either to the liq-uid or the solid phases of the cement) does not interfere in the setting reaction, modifying the physicochemical properties, not only in terms of the setting and harden-ing mechanisms but also with respect to the rheologi-cal behavior. Second, it is necessary to characterize the kinetics of drug release in vitro. Subsequently, the effectiveness of the cement to act as carrier for drug delivery in vivo must be assessed. And finally, the clin-ical performance of the drug delivery system must be evaluated (Ginebra et al. 2006a).

CPCs have been proposed as carriers for biologi-cally active peptides, such as antibiotics (Yu et al. 1992; Bohner et al. 1997; Blom et al. 2001) and bone growth factors (Otsuka et al. 1994; Meraw et al. 2000; Wikesjö et al. 2002; Sorensen et al. 2004). A recent large-scale, prospective, blinded, and randomized con-trolled clinical trial study demonstrated that the use of rhPDGF-BB + b-TCP was safe and effective in the treatment of periodontal osseous defects (Nevins et al. 2005a). The incorporation of platelet-derived growth factor-BB (PDGF-BB) with b-tricalcium phosphate was approved by the FDA in 2004. GEM-21 S™ is a

completely synthetic grafting system for bone and periodontal regeneration launched in 2005. This sys-tem is composed of a purified platelet-derived growth factor-BB (PDGF-BB) and b-tricalcium phosphate matrix (AlGhamdi et al. 2010b).

2.4.5 b-Tricalcium Phosphate (TCP)

Tricalcium phosphate is a porous calcium phosphate compounds (Yamada et al. 2010). Alpha and beta tri-calcium phosphate are produced similarly, although they display different resorption properties. The crys-tal structure of alpha tricalcium phosphate (a-Ca

3(PO

4)

2

is monoclinic and consists of columns of cations, while the beta tricalcium phosphate has a rhombohedral structure. The former is formed by heating the latter above 1,180°C and quenching in air to retain its struc-ture. Alpha form is less stable than beta and forms the stiffer material calcium-deficient hydroxyapatite when mixed with water (Sukumar and Drízhal 2008; TenHuisen and Brown 1998).b-Tricalcium phosphate (b-TCP) is a porous form

of calcium phosphate, with similar proportions of cal-cium and phosphate to cancellous bone (Reynolds et al. 2010). However, the compressive strength of porous TCP reaches only l/20 of cortical bone (Gao et al. 1997; Jarcho 1981). Numerous studies have shown that calcium TCP support the attachment, pro-liferation and differentiation of osteoblasts and mesen-chymal cells as well as bone growth (von Arx et al. 2001; Aybar et al. 2004; Haimi et al. 2009; Jang et al. 2008; Kamitakahara et al. 2008). Tricalcium phosphate ceramic is biocompatible (Metsger et al. 1982) and osteoconductive (Knabe et al. 2000; Ignatius et al. 2001; Hashimoto-Uoshima et al. 1995). The exact mecha nism(s) by which b-TCP exerts osteoconductiv-ity were documented only recently. It was showed that primary human osteoblasts (HOBs) seeded into the b-TCP scaffolds expressed significantly higher levels of osteogenic genes, compared to those cultured on tis-sue culture plastic; meanwhile, these cells showed sev-enfold increase in a2 integrin subunit gene expression and the activation of the mitogen-activated protein kinase (MAPK)/ extracellular-related kinase (ERK) signaling pathway. In addition, the osteogenic conduc-tion by b-TCP scaffolds was attenuated directly by

Fig. 2.21 Microstructure of an apatitic calcium phosphate cement after setting, showing the micro-/nanoporous structure formed by the entanglement of the precipitated crystals (Ginebra et al. 2006a) (Reprinted with permission from Elsevier)


inhibiting MAPK/ERK or indirectly by blocking the a2b1 integrin signaling pathway. It seems that b-TCP scaffold exerts osteoconductivity through a2b1 integ-rin and downstream MAPK/ERK signaling pathway (Lu and Zreiqat 2010a, 2010b).

Physicochemically, b-TCP is a resorbable material with ³99% phase purity (Tadic and Epple 2004), total microporosity and a homogeneous ceramic sinter structure. Thus, optimal matrix for the formation of new bone is available immediately after implantation. Bioresorbability of the calcium phosphate ceramics is governed not only by the solubility of the constituents of the material, but also by morphology implying porosity and pore structure (Kamitakahara et al. 2008). The intergranular spaces provide a scaffold for ingrowths of blood vessels for nutrition of the newly formed bony structures. From the initial stage of bone regeneration, the material is resorbed (Fig. 2.22). Its slow biodegradation property, within 24 months the material is completely metabolized, harmonizes with bone formation and remodeling process and results in a displacement of the material to bone (Ellinger et al. 1986; Artzi et al. 2004; Bokan et al. 2006; Kamitakahara et al. 2008). The resorption mechanism of the formal b-TCP is controversial. It was suggested that the mechanism is mainly dissolution in biological liquids because of the absence of osteoclasts around the mate-rials in rabbit’s experiments (Lu et al. 1998). Cell-mediated bioresorption was also proposed to be a predominant factor in the process of biodegradation of

b-TCP in dog experiments, as considerable numbers of osteoclast-like giant cells and abundant new bone apposition were seen on the b-TCP-implanted defects (Renooji et al. 1985; Neamat et al. 2009).

Despite the promising results in orthopedic surgery (Larsson 2010), b-TCP has provided contradictory evidence in animal (Levin et al. 1974; Barney et al. 1986; Wong et al. 1989; Wada et al. 1989) and human histology studies (Baldock et al. 1985; Dragoo and Kaldahl 1983; Saffar et al. 1990; Froum and Stahl 1987; Stahl and Froum 1986). In dogs, at 16 weeks after the treatment of surgically created three-wall defects, TCP particles were actively resorbed by giant cells and macrophages and were incorporated into new bone matrix (Barney et al. 1986). Similar results were reported in monkeys, where TCP was biodegraded through phagocytosis by histiocytes and multinucle-ated giant cells. The residual particles were incorpo-rated into the new bone matrix and displayed the bone growth guiding property. In the histological features and immunohistochemical analysis of proliferating cell nuclear antigen (PCNA) of the intrabony defects in dogs augmented with b-TCP, osteoid tissue with a platelike structure and cellular mesenchymal prolifera-tion besides osteoid islands joined by bridges were observed after 3 months. Six months after the implan-tation, the b-TCP granules were replaced by abundant new platelike bone besides PCNA-enriched, small, oval-shaped mononuclear cells and multinucleated giant cells that were attached to newly formed bones.

Fig. 2.22 SEM photographs of a commercially available porous b-TCP ceramic (Kamitakahara et al. 2008) (Reprinted with permission from Sage Publications)


No remains of the b-TCP granules could be seen after 3 and 6 months with the newly formed platelike bones and no histological sign of inflammatory reaction or formation of foreign body granulomas (Sugawara et al. 2008). In human histological studies, the TCP particles were encapsulated by fibrous connective tissue, but the particles did not stimulate new bone growth, with residual graft particles evident 18 months following treatment. Although new cementum was observed, there was limited evidence of new attachment (Baldock et al. 1985; Dragoo and Kaldahl 1983; Saffar et al. 1990; Froum and Stahl 1987; Stahl and Froum 1986). Stavropoulos et al. 2010 indicated that the clinical improvements (i.e., PD reduction and CAL gain) obtained after implantation of a granular b-TCP prod-uct adjunctively with open flap debridement of peri-odontal intrabony defects were, in part, characterized by regeneration (although minimal in amount), whereas the major portion of healing occurred with the forma-tion of a long junctional epithelium on the previously affected root surface. In most specimens, b-TCP par-ticles were embedded in the connective tissue, whereas the formation of a mineralized bone-like or cementum-like tissue around the particles was only occasionally observed. In all of the specimens, ghost images of graft particles, appearing as empty spaces due to the decal-cification procedure, were observed. The graft particles appeared not to have any apparent association with bone formation, and the major portion of the periphery of the particles was in contact with fibrous connective tissue. A thin layer of a mineralized, occasionally cel-lular substance in direct contact with some portion of the periphery of the particles was only sporadically observed, and the presence of osteoclasts in contact with the particles was not obvious. The histologic eval-uation indicated the formation of new cellular cemen-tum with inserting collagen fibers to a varying extent (mean: 1.9 ± 0.7 mm; range: 1.2–3.03 mm) coronal to the most apical extent of the root instrumentation. The mean new bone formation was 1.0 ± 0.7 mm (range: 0.0–1.9 mm) (Stavropoulos et al. 2010).

Clinical studies reported improvements in clinical outcomes, including clinical attachment level, after the treatment of intrabony periodontal defects involving surgical implantation of b-TCP (Nery and Lynch 1978; Louise et al. 1985; Detienville et al. 1986; Evans et al. 1989; Snyder et al. 1984; Strub et al. 1979; Palti and Hoch 2002; Stavropoulos et al. 2010). Stavropoulos et al. (2010) reported a mean probing depth reduction

from 10.8 ± 2.3 mm presurgically to 4.6 ± 2.1 mm, and a mean clinical attachment level (CAL) gain of 5.0 ± 0.7 mm was observed. The increase in gingival recession was 1.2 ± 3.2 mm.

Bokan et al. (2006) found that the treatment of deep intrabony defects with Emdogain (EMD) either alone or in combination with b-TCP led to a clinically and statistically significant reduction of probing depth (PD) and gain in clinical attachment (CAL). The addi-tional application of b-TCP showed no clear superi-ority to treatment with Emdogains alone. Treatment with EMD alone yielded a 3.9 ± 1.3-mm PD decrease and a 3.7 ± 1.0-mm CAL gain (P < 0.001), whereas EMD + b-TCP produced a 4.1 ± 1.2-mm PD reduction and a 4.0 ± 1.0-mm PAL gain (P < 0.001).

Several commercial available TPC products are avail-able on the market: Bioresorb® is available as porous granulate (particle size: 0.5–2 mm) mainly for dental application. Chronos® and Ceros® (Mathys, Bettlach, Switzerland) are also granular materials with a parti-cle size of 0.5–1.4 mm and pore sizes of 100–500 mm (60% pore volume), also mainly for dental applica-tion. Cerasorb® (Curasan, Kleinostheim, Germany) is available as porous granulate (pore size >5 mm) in particle sizes of 0.05–2 mm (grain sizes: 50–150 mm, 150–500 mm, 500–1,000 mm, 1,000–2,000 mm) for dental application and as machined macroporous blocks for orthopedic applications (Fig. 2.23). Vitoss® is a porous granulate (pore size 10–1,000 mm; porosity approx. 90%; particle size 3–5 mm) for dental appli-cation (Tadic and Epple 2004). SynthograftTM (Bicon, Boston MA, USA) is available in two particle sizes: 50–500 mm and 500–1,000 mm.

Biphasic alloplastic material is produced by sinter-ing hydroxyapatite (HA) and tricalcium phosphate to a chemically united material, with pore sizes of >100 mm (Fig. 2.24). Synthetically produced alloplasts used in implant dentistry include Calcitec® Inc. (Austin, TX), Osteogen® (Impladent Ltd, Holliswood, NY), Tricos® (Baxter, Bern, Switzerland), MBCP (Biomatlante, Vigneux de Bretagne, France), OsteonTM (Genoss Co. Ltd., Suwon, Korea) and Bone Ceramic® (Straumann, Basel, Switzerland). However, sufficient documenta-tion of the clinical utility of several of these alloplasts is still lacking (Hallman and Thor 2008). OsteonTM (Genoss Co. Ltd., Suwon, Korea) is composed of 70% HA and 30% b-tricalcium phosphate (b-TCP). HA coated with b-TCP establishes an interconnected scaf-fold with a porosity of 300–500 nm (Lee et al. 2010).


Ceraform® is a commercially available ceramic, manu-factured by Teknimed SA (Vic-en Bigorre, France). This material is a synthetic biphasic ceramic made of 65% HA and 35% TCP. The material is available as a block or granular form and sterilized by gamma radia-tion. The mean granular diameter is between 900 and

1,200 mm (Develioglu et al. 2006). BoneCeramic® is a composite of medical purity biphasic calcium phos-phate: a mixture of 60% hydroxyapatite, which is 100% crystalline, and 40% of the b form of TCP in particulate form. The graft material is 90% porous with interconnected pores 100–500 mm in diameter.

Fig. 2.23 SEM pictures of four representative bone graft materials. (a) Cerasorb®, (b) Cerabone®, (c) Algipore® and (d) Tutoplast® (bovine) (Tadic and Epple 2004) (Reprinted with permission from Elsevier)


d

Fig. 2.23 (continued)

a b

c d

Fig. 2.24 Structural profile of porous biphasic calcium phos-phate (PBCP). (a) The aspect of PBCP sample. (b) 3D recon-struction image of BCP by mCT. (c) Reconstruction transect image of PBCP by mCT. (d) XRD photograph of PBCP showed that only HA and b-TCP phases were defected. (e) SEM micro-

graphs of macropores in PBCP block (×120). Bar scales, 1 mm; (f) SEM micrographs of micropores in the wall of macropores, magnified view of (b) (×20,000). Bar scales, 5 mm (Wang et al. 2010) (Reprinted with permission from Springer)


e f


Nery et al. (1992) suggested that higher HA ratio showed accelerated new bone formation and new attachment levels and demonstrated the superiority of using a composite of these two materials over the use of either material alone. This grafting material was used in periodontal, peri-implant and various types of bone defects (Gauthier et al. 1999; Piattelli et al. 1996b; Shi et al. 2008; Zafiropoulos et al. 2007; Schwarz et al. 2007; Jensen et al. 2007; Sculean et al. 2008; Wang et al. 2010; Choi et al. 2010) (Fig. 2.25). The combina-tion of Emdogain with a HA/bTCP bone substitute did not interfere with the regenerative potential reported for EMD and may result in formation of new cementum with an associated periodontal ligament. However, the combination of Emdogain + HA/bTCP resulted in no to minimal new bone formation (Sculean et al. 2008). However, it has been showed that HA/b-TCP mixed with autogenous spongiosa treatments produced significantly better outcomes than autogenous spongiosa alone in intrabony tissue regeneration (Zafiropoulos et al. 2007).

Some alloplastic materials are mixed together to achieve superior results. Fortoss® Vital (Biocomposites, Staffordshire, UK) is such a mixture of b-TCP and calcium sulfate (Sukumar and Drízhal 2008). Due to modified surface activity and ion loading, its osteocon-ductive behavior might be superior to conventional cal-cium phosphates. In contrast to conventional b-TCPs, manufacturing and application of this biphasic cal-cium composite material use a proprietary process (Zeta Potential Control, Biocomposites) to establish

a negative zeta potential. Based on this concept, the surface of the material will be charged negatively in an aqueous environment (Stein et al. 2009). Zeta poten-tial is an effective predictor of biomaterial attraction to osteoblasts and bone, providing a useful in vitro method for predicting such interactions (Smith et al. 2004; Ohgaki et al. 2001). The application of the b-TCP and calcium sulfate material was well tolerated and led to superior PD and CAL changes compared to open flap debridement for the treatment of intrabony periodon-tal defects. The clinical benefits of BCC were equiva-lent to autogenous bone spongiosa (Stein et al. 2009). At 12 months, patients treated with b-TCP and calcium sulfate exhibited a mean PD reduction of 3.6 ± 0.7 mm and a mean CAL gain of 3.0 ± 0.8 mm compared to baseline. Corresponding values for patients treated with autogenous bone spongiosa were 3.4 ± 0.8 mm and 2.9 ± 0.9 mm, whereas open flap debridement sites produced values of 2.8 ± 0.8 mm and 1.6 ± 0.7 mm.

Calcium phosphates can be bound to collagen carriers or mixed with fibrin. The concept is that collagen and fibrin form a network on which minerals can crystallize. Collagen can also bind to extracellular matrix (ECM) pro-teins of importance in the mineralization process. Healos® (Orquest, Mountain View, CA) is a mixture of hydroxy-apatite and bovine collagen and Collagraft® (Zimmer Corp., Warsaw, IN) is composed of 65% hydroxyapatite and 35% tricalcium phosphate combined with bovine col-lagen. Tricos® is a mixture of hydroxyapatite, tricalcium phosphate and fibrin (Hallman and Thor 2008).


Fig. 2.25 Photomicrograph of healing of acute alveolar bone dehiscence following treatment with porous biphasic calcium phosphate in beagle dogs. The sections of a, c, e and g were stained with toluidine blue; the sections of b, d, f and h were stained with hematoxylin and eosin (yellow arrows pointed to the notch, yellow lines marked the height of the new alveolar bone, NB new bone, DE dentin, HB host bone, PDL periodontal ligament); (a) 16 weeks in PBCP: healing resulted in abundant periodontal regeneration (×40); (b) 12 weeks in PBCP: new collagen fiber bundles mostly inclined to the crown with one end embedded in cementum higher than the other end buried in adjacent bone (×400); (c) 16 weeks in PBCP, magnified view of yellow rectangle in (a): most fiber bundles aligned in vertical to

the root surface (×200); (d) 24 weeks of PBCP: new collagen fiber bundles were in functional arrangement at right angles (×400); (e) 16 weeks in OFD: limited new alveolar bone formed in the defect and covered the notch at most (×40); (f) 12 weeks in OFD: new mixed cementum without inserting collagen fibers deposited on the root surface in the notch, the new PDL were thin and little, which parallel to the root surface (×400); (g) 16 weeks in OFD, magnified view of (e), newly formed PDL were parallel to the root surface (×200); (h) magnified view of normal PDL just below the notch, collagen fiber bundles arranged orderly with one end embedded in cementum lower than the other end buried in adjacent bone at about 45° (×400) (Wang et al. 2010) (Reprinted with permission from Springer)


In the recent years, increased efforts have been focused on understanding the mechanisms of and fac-tors required for restoring periodontal tissues in order to increase the predictability of regenerative therapy. These events are controlled by biological mediators like growth factors, morphogenetic proteins, ECM proteins and oth-ers, which are produced by monocytes, platelets and resident tissue cells like PDL cells, osteoblasts, cemen-toblasts and endothelial cells (Christgau et al. 2006). Several studies have shown that periodontal regenera-tion may be enhanced by the therapeutic application of specific growth factors to tricalcium phosphates, such as basic fibroblast growth factor (bFGF) (Shirakata et al. 2010), growth/differentiation factor-5 (Kwon et al. 2010) and platelet-derived growth factor (PDGF)

(Nevins et al. 2005a; Sarment et al. 2006; McGuire et al. 2006; Nevins et al. 2007; Yassibag-Berkman et al. 2007; Döri et al. 2008; Ridgway et al. 2008; Mellonig et al. 2009; McGuire et al. 2009a; McGuire et al. 2009b).

2.4.6 Calcium Sulfate

Calcium sulfate, generally known as plaster of Paris, or gypsum, is perhaps, the oldest ceramic bone substitute material. Given the relatively simple chemistry of cal-cium sulfate, there is less latitude for formulation varia-tion than is the case in the calcium phosphate domain. Traditionally, calcium sulfate hemihydrate (CaSO

4 ×

1/2H2O) powder is hydrated to form calcium sulfate



dihydrate (CaSO4 × 2H

2O), undergoing a slight exother-

mic reaction to set to a solid form (Eppley et al. 2005).Calcium sulfate resorbs quickly, over a period of

12 weeks, by a process of dissolution and is substituted by new bone (Bell 1964). The rapid resorption rate can pose a potential problem because the volume of the graft may not be maintained for a sufficiently long period of time to yield reliable grafting results in the esthetic zone (Hallman and Thor 2008).

Calcium sulfate has been considered inexpensive, readily available, easy to sterilize, safe and simple to use, eliciting little or no macrophagic reaction, does not adversely impact the cell proliferation kinetics (Winn and Hollinger 2000; Hogset and Bredberg 1986) and does not elevate serumcalcium levels (Elkins and Jones 1988).

Calcium sulfate graft material with a patented crys-talline structure described as an alphahemihydrate acts primarily as osteoconductive bone-void filler that com-pletely resorbs as newly formed bone remodels and restores anatomic features and structural properties. (Nandi et al. 2010). Although the exact mechanism of action remains undiscovered, calcium sulfate appears to function as a resorbable osteoconductive scaffold that provides the structural framework necessary for angio-genesis and osteogenesis while preventing soft tissue invasion by acting as a space filler. It was indicated that calcium sulfate pellets placed into a large animal meta-physeal defect was equivalent to autogenous and allo-genic bone in terms of bone-volume production and significantly better than the empty control, as evidenced by backscattered electron microscopy. Histologically, the quality of bone formed in defects treated with cal-cium sulfate was not discernable from that formed when defects were treated with autogenous or allogenic bone. The histological response was characterized by relative completion of bone formation as evidenced by newly remodeled bone (Peters et al. 2006).

Example of commercially available calcium sul-fate graft is Capset®, Lifecore Biomedical, Chaska, MN. CalFormaTM Calcium Sulfate Bone Graft Barrier is a modification of Lifecore Biomedical’s Capset® Calcium Sulfate Bone Graft Barrier. The modifica-tion is the addition of a small amount of an excipient, HPMC (hydroxypropyl methylcellulose or hypromel-lose), to the accelerated calcium sulfate in order to improve handling characteristics of the device when used as a barrier over bony defects in dental applica-tions (FDA 2010e). Lifecore Biomedical CalMatrix Calcium Sulfate Bone Graft Binder (CalMatrix) is a calcium sulfate material that contains resorbable

surgical grade plaster of Paris with approximately 10% of a pharmaceutical grade sodium carboxymethylcel-lulose. CalMatrix and Allomatrix® (Wright Medical Technology, Inc) utilize the same calcium sulfate (CS)/CMC blend, except that Allomatrix is provided with human demineralized bone matrix (DBM) already mixed in. CalMatrix is to be mixed with DBM or other bone graft material by the clinician prior to applica-tion (FDA 2010e). Currently, medical grade calcium sulfate impregnated with tobramycin is commercially available (Osteoset®; Wright Medical Technology, Arlington, TN, USA) (Sukumar and Drízhal 2008). A novel biphasic calcium composite grafting material that consisted of a porous b−tricalcium phosphate and calcium sulfate phase was recently presented (Fortoss Vital, Biocomposites, Keele, UK).

Potential application of calcium sulfate graft mate-rial includes the filling of cysts, bone cavities, benign bone lesions and segmental bone defects; expansion of grafts used for spinal fusion; and filling of bone graft harvest sites. Significant loss of its mechanical proper-ties occurs upon its degradation; therefore, it is a ques-tionable choice for load-bearing applications (Nandi et al. 2010). Another indications include also repair of furcation perforations (Rafter et al. 2002).

Because of its beneficial properties, calcium sulfate alone or associated with other types of materials, such as autologous bone, was used in the treatment of peri-odontal intrabony defects and furcation lesions (Stein et al. 2009; Paolantonio et al. 2008; Orsini et al. 2008; Harris 2004; Aichelmann-Reidy et al. 2004; Maragos et al. 2002; Orsini et al. 2001; Setya and Bissada 1999; Rosen and Reynolds 1999; Kim et al. 1998; DiBattista et al. 1995; Hashimoto 1983; Shaffer and App 1971).

The addition of DFDBA to calcium sulfate signifi-cantly enhanced the clinical outcome more than did the calcium sulfate alone (Maragos et al. 2002) or when compared to surgical debridement only (Setya and Bissada 1999; Kim et al. 1998). The ability to mix cal-cium sulfate with a graft material, such as DFDBA, has a number of distinct advantages. Conceptually, the cal-cium sulfate carrier should act as a binder to minimize the graft scatter, facilitate graft retention, decrease graft exposure and maintain the space necessary to permit regenerating tissues to occupy the osseous defect. Aichelmann-Reidy et al. (2004) indicate that calcium sulfate, when used as a binder and barrier in combination with DFDBA, supports significant clini-cal improvement in intrabony defects, as evidenced by reductions in probing depth, gains in clinical attach-ment level and defect fill and resolution. Calcium


sulfate represents an important alternative to non-resorbable ePTFE barriers in combination with DFDBA for the treatment of intrabony defects, with less morbidity and cost for the patient (Aichelmann-Reidy et al. 2004). No significant differences were seen between calcium sulfate graft and membrane ver-sus guided tissue regeneration with collagen membrane alone (Paolantonio et al. 2008) or between the results obtained using the combination of autogenous bone grafting plus calcium sulfate or autogenous bone graft-ing with a bioabsorbable membrane (Orsini et al. 2008; Orsini et al. 2001).

Some alloplastic materials are mixed together to achieve superior results. Fortoss® Vital (Biocomposites, Staffordshire, UK) is such a mixture of beta trical-cium phosphate and calcium sulfate (Sukumar and Drízhal 2008).

2.4.7 Bioactive Glasses (BG)

Among the different alloplastic materials used in peri-odontal therapy, hydroxyapatite, calcium phosphates and bioactive glass ceramics share a common factor, which is their capacity to form a carbonated hydroxy-apatite layer on their surfaces once exposed to simu-lated body fluids or implanted in vivo, hence the concept of “bioactivity.” Since their invention three decades ago by Hench et al. (1971) bioactive glasses have clinically gained wide acceptance in restorative orthopaedics and dentistry (Hattar et al. 2005).

The original composition of bioactive glass approved by the FDA, designated 45 S5, was composed of 46.1 mol% SiO

2, 26.9 mol% CaO, 24.4 mol% Na

2O,

and 2.5 mol% P2O

5. The original composition and fine

structure has been extensively modified in an attempt to further enhance bioactive glass as a bone replace-ment graft (Reynolds et al. 2010; Hench 2006). When a bioactive glass is implanted in vivo, the pH of the site increases close to 10, a layer rich in silica gel is formed on the surface of the particles and a subsequent calcium phosphate layer is formed by the interaction between calcium and phosphate from the bioactive glass and tis-sue fluids. The calcium phosphate layer is composed of hydroxycarbonate apatite that is chemically and struc-turally equivalent to bone mineral composition (Villaça et al. 2005; Hench & Wilson et al. 1984) (Fig. 2.26).

The material is easy to manipulate and it is hemo-static (Wilson and Low 1992; Low et al. 1997; Zamet et al. 1997; Froum et al. 1998; Lovelace et al. 1998; Sculean et al. 2002a). The bioactive glass particles

formed a cohesive mass when wetted with blood, which allowed very easy manipulation and packing into the extraction sockets or periodontal defects (Schepers et al. 1998). This transparent bioactive mate-rial has proven ability to bond to connective tissue and bone without an intervening fibrous connective tissue interface (Wilson and Low 1992). Upon contact with body fluid, there is an immediate exchange of ions which results in a physiochemical bond between Bioglass, soft tissue and bone. The ion exchange cre-ates an environment resulting in the formation of a hydroxyl-carbonate apatite layer (HCA), a biological apatite identical to the mineral phase of bone, which allows for more rapid repair and regeneration of bone than other synthetic graft materials (Wilson and Low 1992; Shapoff et al. 1997).

a

Counts

300Si

O Na

P

Ca

100

01 2 3 4 5

200

Energy (KeV)

b

Fig. 2.26 Porous structures and chemical composition of glass ceramic: (a) porous structures of glass ceramic under SEM observation and (b) EDX analysis of glass ceramic (Yuan et al. 2001) (Reprinted with permission from John Wiley & Sons)


It was showed that bioactive glass several antibac-terial effect against on a large panel of clinically important bacterial species (A. actinomycetemcomi-tans, P. gingivalis, Actinomyces naeslundii, Fusobacte-rium nucleatum, Prevotella intermedia, Streptococcus mutans, and Streptococcus sanguis, Candida albicans) (Stoor et al., 1998; Allan et al, 2001; Allan et al, 2002; Yli-Urpo et al., 2003; Zehnder et al., 2004; Munukka et al., 2008; Hu et al., 2009).

Bioglass is capable of promoting osteoblast cellular proliferation and differentiation (Price et al. 1997; Xynos et al. 2000a; Vrouwenvelder et al. 1993; Xynos et al. 2000b; Hattar et al. 2005; Palmieri et al. 2008) and acts on bone formation by determining both osteoconduc-tion (as demonstrated by the reduced cell adhesion) and osteogenesis (as shown by TGFb-related proteins and stem cell markers) (Carinci et al. 2007). Bioactive glass is a particulate bioactive ceramic, which has the ability to bond to bone tissue and enhance bone growth because of its osteoconductive properties. In addition to its osteo-conductive properties, it also has an osteostimulatory effect showing bone growth within eroded particles. These islands of newly formed bone tissue function as nuclei for further bone growth and enhance the repair of osseous defects. This new bone has the histologic and biomechanical properties of surrounding bone as soon as 7 months after grafting (Furusawa et al. 1998; Throndson and Sexton 2002) (Fig. 2.27).

Treatment of two-wall intrabony defects in mon-keys demonstrated that bioactive glass had better heal-ing potential than debridement only. Bioactive glass showed an inhibitory property on the apical migration of the junctional epithelium. It was observed that in the sites treated with the bioactive glass, the junctional epithelium migrated apically to the level of the parti-cles most coronally located inside the defect, not sur-passing this point (Villaça et al. 2005). Karatzas et al. (1999) in a histological study in monkeys reported sig-nificantly more new cementum and less epithelial downgrowth in the sites that received bioactive glass. However, in human histological studies, a low poten-tial to facilitate periodontal regeneration was demon-strated as there was minimal new bone formation limited to the most apical borders of the defects. No signs of periodontal regeneration as defined by new cementum, periodontal ligament and bone formation on a previously diseased root surface were observed (Nevins et al. 2000; Sculean et al. 2005c).

In treatment of periodontal intrabony osseous defects or furcation lesions, Bioglass was used either alone (Froum et al. 1998; Ong et al. 1998;

a

ceramic

b

ceramicc

Fig. 2.27 Histological observation of bone formation induced by glass ceramic: (a) an overview of a histological section (bar = 700 mm), (b) a high magnification of square a in (a) (bar = 50 mm), (c) a high magnification of square b in (a) (arrow: intramembranous ossification, bar = 100 mm) (undecalcified section, methylene blue and basic fuchsin staining) (Yuan et al. 2001) (Reprinted with permission from John Wiley & Sons)


Rosenberg et al. 2000; Park et al. 2001; Zamet et al. 1997; Anderegg et al. 1999; Yukna et al. 2001; Park et al. 2001; Mengel et al. 2003, 2006; Dybvik et al. 2007; Leknes et al. 2009), with GTR membranes (Keles et al. 2006), with platelet-rich plasma (Demir et al. 2007a, 2007b) or with enamel matrix deriva-tive (EMD) (Sculean et al. 2002a, 2005b, 2005c, 2007a; Kuru et al. 2006).

Treatment of intraosseous defects by means of bio-active glass resulted in an improvement of the bony lesion when compared to the OFD procedure. Weighted mean difference in clinical attachment level gain between bioactive glass and OFD was reported to be 1.04 mm (95% CI: 0.31–1.76) by Trombelli et al. (2002) and 1.05 ± 1.89 mm by Reynolds et al. (2003), while for the PD change, the weighted mean difference was 0.6 mm (95% CI: 0.20–1.002) (Trombelli et al. 2002), and 0.71 mm ± 2.22 mm (Reynolds et al. 2003), respectively.

Leknes et al. (2009) examined the clinical efficacy of EMD and BG in the treatment of proximal intra-bony periodontal defects and to evaluate factors influ-encing the treatment outcome. The gain in proximal attachment after treating intrabony defects by flap sur-gery with BCF was significant (P = 0.004) and twice that following treatment with EMD (P = 0.056). Patient and site variables affected the clinical outcome differently. Regression analysis revealed that within the EMD group, smoking and tooth mobility nega-tively influenced the gain of attachment, whereas within the BG group, gingival recession increased with age, increasing cemento-enamel junction to buc-cal crest distance and increasing mesial-distal width of the defect.

The combination of enamel matrix derivative and bioactive glass does not seem to additionally improve the clinical results when compared with enamel matrix derivative alone (Sculean et al. 2002a; Sculean et al. 2005b; Sculean et al. 2007a). Kuru et al. (2006) reported for both treatments marked clinical and radiographical improvements, but showing that com-bined treatment seemed to enhance the results in the treatment of wide intrabony defects. The two groups, EMD and EMD + BG, presented a mean pocket reduc-tion of 5.03 ± 0.89 and 5.73 ± 0.80 mm, recession of 0.97 ± 0.24 and 0.56 ± 0.18 mm, relative attachment gain of 4.06 ± 1.06 and 5.17 ± 0.85 mm, and radio-graphic bone gain of 2.15 ± 0.42 and 2.76 ± 0.69 mm,

respectively. It was indicated that the clinical improve-ments obtained with both regenerative modalities can be maintained over a period of 4 years (Sculean et al. 2007a) (Figs. 2.28 and 2.29).

Platelets contain high concentrations of PDGF and TGF-b in their a granules and the preparation of platelet-rich plasma (PRP) seems to be an appropriate and economical method to obtain these growth factors autogenously (Demir et al. 2007a). Demir et al. (2007b) compared the use of either PRP + BG to BG alone in the treatment of patients with interproximal probing depth ³6 mm following initial therapy. Clinical parameters were recorded at baseline and repeated 9 months after surgery and surgical reentries were also performed. The results showed that both treatment modalities were effective. Pocket depth reduction of 3.60 ± 0.51 mm, clinical attachment gain of 3.3 ± 1.77 mm and defect fill of 3.47 ± 0.53 mm were noted in the PRP/BG group, with 3.29 ± 1.68, 2.86 ± 1.56 and 3.36 ± 0.55 mm improvements, respectively, noted for the BG group. None of the differences between the two treatment modalities were statistically significant.

When the long-term effectiveness of a bioabsorb-able membrane and a bioactive glass in the treatment of intrabony defects in patients with generalized aggres-sive periodontitis was performed, highly significant improvements in the parameters PD and CAL were recorded after 5 years with both regenerative materials. Reduction in PD of 3.6 ± 0.8 mm (P = 0.016) and a gain in CAL of 3.0 ± 2.0 mm (P = 0.01) were registered in the membrane group. There was a slight increase in GR by 0.6 ± 1.4 mm (P = 0.334). In the PG group, a reduc-tion in PD of 3.5 ± 1.4 mm (P = 0.01) and a gain in CAL of 3.3 ± 2.1 mm (P = 0.01) were recorded, whereas GR increased by 0.2 ± 1.7 mm (P = 0.525). Radiographically, the defects were found to be filled significantly more in the bioactive glass group (Mengel et al. 2006). Equal clinical results with bioactive glass and ePTFE barriers in mandibular molar Class II furcations were obtained (Yukna et al. 2001). However, bioactive glass was asso-ciated with simpler application and required no addi-tional material removal procedures.

Moreover, in soft and hard tissue measurements, no significant differences were reported between demineralized freeze-dried bone allografts (DFDBA) and BG grafted sites (Lovelace et al. 1998). The results indicated that probing depths were reduced by 3.07 ± 0.80 mm with the bioactive glass and


2.60 ± 1.40 mm with DFDBA. Sites grafted with bioac-tive glass resulted in 2.27 ± 0.88 mm attachment level gain, while sites grafted with DFDBA had a 1.93 ± 1.33 mm gain in attachment. Bioactive glass sites displayed 0.53 ± 0.64 mm of crestal resorption and 2.73 mm bone fill. DFDBA-grafted sites experi-enced 0.80 ± 0.56 mm of crestal resorption and 2.80 mm defect fill. The use of bioactive glass resulted in 61.8% bone fill and 73.33% defect resolution. DFDBA-grafted defects showed similar results, with 62.5% bone fill and 80.87% defect resolution. Both treatments pro-

vided soft and hard tissue improvements when com-pared to baseline (P £ 0.0001).

The significant base of scientific studies conducted using Bioglass, along with the required biocompatibil-ity and toxicology studies required by the regulatory bodies have provided a strong basis for establishing the safety of Bioglass devices placed into commerce (Hench 2006).

While the second-generation Bioglass materials performed admirably in replacing diseased or miss-ing hard tissue, the discoveries that Bioglass could

a

c

d

e

b

Fig. 2.28 Enamel matrix derivative in combination with a bioactive glass in wide intrabony defects. (a) A preoperative radiograph revealing the presence of an intrabony defect. (b) Intrabony component of the defect. (c) The horizontal width of the defect. (d) The clinical appearance of the defect filled with the combination of enamel matrix derivative and bioactive glass at 8 months. (e) Radiographic appearance at 8 months postoperatively (Kuru et al. 2006) (Reprinted with permission from Springer)


positively affect osteoblasts, and in fact “stimulate” them to produce more bone tissue earlier than other synthetic biomaterials led to the concept of “osteo-production” and “osteostimulation.” In order to take advantage of this property, and of the need to regen-erate diseased or missing tissues, the development of third-generation Bioglass products focused on

using particles rather than monolithic shapes. The products are being manufactured and sold to the clinic under the name NovaBone (Hench 2006).

The first NovaBone particulate material cleared for sale in the USA was Perioglas®, which was cleared via the 510[k] process in December, 1993. In 1995, PerioGlas obtained a CE Mark and marketing of the product began in Europe. The initial indication for the product was to restore bone loss resulting from periodontal disease in infrabony defects. In 1996, additional indications for use were cleared by FDA, including use in tooth extraction sites and for alveolar ridge augmentation (Hench 2006).

PerioGlas® (Block Drug Co., NJ, USA) is a syn-thetic absorbable osteoconductive bone graft substi-tute composed of a calcium phosphosilicate bioactive glass, Bioglass. The device is in a particulate form of a size range 90–710 mm. The device is intended for dental intraosseous, oral and cranio-/maxillofacial bony defects. It is supplied sterile, packaged either in a Tyvek-sealed PET-G cup or in a filled syringe within a second sterile barrier package. The device packages are protected by an outer shrink-wrapped cardboard box. At time of use, the device is mixed with sterile water, saline, the patient’s own blood or marrow or with autogenous or allograft bone to form a wet sandy paste that is applied to the defect (FDA 2010a).

PerioGlas® Plus (Block Drug Co., NJ, USA) is a synthetic resorbable osteoconductive bone graft sub-stitute composed of a calcium phosphosilicate material and a calcium sulfate binder. The device is intended for dental intraosseous, oral and maxillofacial bony defects. The inorganic calcium and phosphorous components are thermally incorporated in a sodium silicate network (PerioGlas®) designed specifically for its absorbability and osteoconductive nature. The cal-cium sulfate component binds the PerioGlas® particles together at the time of implantation and is absorbed from the graft site over the first several weeks follow-ing implantation. On absorption of the calcium sulfate, the PerioGlas® particles remain in the graft site and are progressively absorbed and replaced by host bone dur-ing the healing process (FDA 2010b).

The main technological characteristic difference between PerioGlas® Plus and the predicate devices is their composition. PerioGlas® is composed of particulate Bioglass. Capset (Lifecore Biomedical,

a

b

c

Fig. 2.29 Enamel matrix derivative alone in wide intrabony defects. (a) A preoperative radiographic appearance. (b) Intrabony component of the defect. (c) At 8 months after treat-ment with enamel matrix derivative (Kuru et al. 2006) (Reprinted with permission from Springer)


Chaska, MN) is composed of powdered calcium sulfate hemihydrate which, when combined with an aqueous-based setting solution, is chemically con-verted to calcium sulfate dihydrate. PerioGlas® Plus is composed of particulate Bioglass and powdered calcium sulfate hemihydrate; when mixed with water, the hemihydrate is chemically converted to calcium sulfate dihydrate and acts as a binder for the Bioglass particles. The calcium sulfate in the PerioGlas® Plus and Capset devices is absorbed between 4 and 8 weeks after implantation, depend-ing on the graft site, size and material used. The particulate Bioglass in the PerioGlas® Plus device is identical to that in the PerioGlas® predicate, being substantially absorbed within the 6-month time frame normally associated with bone remod-eling. For all three devices, bone forms throughout the graft site with the material being absorbed and replaced by new bone tissue (FDA 2010b).

Biogran™ (Orthovita Inc., Malvern, PA, USA) is a particulate bioactive glass, which has been used in a few experimental and clinical studies for the treatment of different types of bone defect, BioGran™ is a resorb-able bone graft material consisting of 300–355 mm diameter bioactive glass particle size. It has the ability to bond to soft and bone tissue and, in addition, it enhances bone tissue growth due to its osteoconductive properties (Schepers et al. 1991, 1993; Kontonasaki et al. 2007).

Unigraft® (Unicare Biomedical Inc., Laguna Hills, CA, USA) is a synthetic bioactive glass that is intended to use in the repair oral/maxillofacial and dental intraosseous defects. The bioactive glass (CaO, Na

2O, P

2O

5 and SiO

2) used in Unigraft® is manufac-

tured as irregular-shaped synthetic granules, sized from about 200 mm to about 420 mm. It is supplied sterile in foil-sealed polyolefin vial. The product is to be mixed with sterile saline or with patient’s blood to form a sandy paste that is to be applied to the defect (FDA 2010c).

More recently, Bioglass particulate has been used for the treatment of dentinal hypersensitivity. Tooth hypersensitivity is a problem that affects an estimated 15–20% of the population of the USA, and similar numbers in Europe. Tooth hypersensitivity occurs when the root portion of the tooth, which is dentin, becomes exposed around the gum line. The dentin has small openings, or tubules, that communicate with the

pulp chamber. If the dentinal tubules become exposed, hot or cold or pressure can transmit the sensations to the nerves in the pulp, causing pain. The Bioglass material used in this application is a very fine particu-late that is incorporated into toothpaste, or used with an aqueous vehicle and applied to the tooth surface around exposed root dentin. When Bioglass particles are put in contact with dentin, they adhere to the sur-face, rapidly form a hydroxycarbonate apatite layer and occlude the tubules, thereby relieving the pain (Hench 2006). Studies have shown that the Bioglass particulate could produce considerable sealing depth in dentinal tubules with the potential of prolonging the therapeutic effect efficaciously (Curtis et al. 2010; Chiang et al. 2010; Lee et al. 2007; Lee et al. 2005; Kuo et al. 2007).

Other dental and maxillofacial applications include pulp capping (Stanley et al. 2001; Oguntebi et al. 1993), for bone formation in combination with implants and sinus lift procedures (Govindaraj et al. 1999; Browaeys et al. 2007; Precheur et al. 2007), including its use in solid root form in extraction sockets as endog-enous ridge maintenance implants (Stanley et al. 1987; Wilson et al. 1993a; Kirsh and Garg 1994), for filling oral cystic cavities or after apicoectomies (Shapoff et al. 1997).

2.4.8 Oily CaOH2 Suspension

Calcium hydroxide (CaOH2) is a product of lime slak-

ing from quicklime (CaO) and is used extensively in endodontics, combined with various vehicles for indi-rect and direct pulp-capping procedures and as a tem-porary root-filling material, where it has been shown to support hard tissue repair. Recently, a non- setting oily CaOH

2 suspension (OCHS; Osteoinductal®,

Osteoinductal GmbH, Munich, Germany) has been introduced into the market for application in jaw-bone surgery. This formulation contains, apart from CaOH

2, liquid and solid carbohydrate chains and

various fatty acids (e.g., oleic, palmitoleinic, gado-leinic, margarine, pentadecane, myristic, linolenic, stearic, arachidic, lauric) esterified with glycerol, while the oily part consists of a natural product of porcine origin, oleum pedum and vaselinum album (Stavropoulos et al. 2007).


Results from pilot studies in experimental animals suggest that OCHS may accelerate bone healing and promote periodontal regeneration (Ito et al. 2002; Schwarz et al. 2006b). In a study in rats, Ito et al. (2002) compared the healing in OCHS-filled extrac-tion sockets with that in sockets left untreated to serve as controls. The authors reported that after 1 month of healing, the sockets previously filled with OCHS showed statistically significantly larger amounts of bone fill than the controls. In dogs, three-wall intra-bony periodontal defects were bilaterally produced and were randomly treated with both access flap sur-gery and the application of OCHS or access flap sur-gery alone. After 2 months of healing, larger amounts of regenerated bone and newly formed cementum were observed in the sites treated with OCHS than that found in the control sites, in which healing was pre-dominantly characterized by the formation of a long junctional epithelium along the previously denuded root surface and only minimal bone regeneration (Schwarz et al. 2006b) (Fig. 2.30). In contrast with the previous reports, Stavropoulos et al. (2007) clearly demonstrated in an experimental study in rats that

OCHS does not promote bone formation when used as an adjunct to GBR, but on the contrary it may hamper it. It was also indicated that the use of the calcium hydroxide suspension. Osteoinductal has a detrimental effect on wound healing and osseointegration of dental implants and cannot be recommended for use with dental implants (Kohal et al. 1997). An in vitro study indicated that Osteoinductal enhances the mitogenic response of human PDL cells by activation of ERK1/2 and increases cell proliferation; however, it is inferior in comparison to EMD (Kasaj et al. 2007).

Recent clinical studies have shown that an oily cal-cium hydroxide suspension, applied to the root sur-face in conjunction with surgical periodontal therapy, may promote periodontal regeneration (Stratul 2003; Stratul and Sculean 2004; Stratul et al. 2006). OCHS resulted in statistically significant higher pocket depth reductions and clinical attachment level gains than access flap surgery alone. At 6 months after surgery, the test group showed a reduction in mean PD from 7.7 ± 1.5 to 2.9 ± 0.9 mm (P < 0.001) and a change in mean CAL from 9.6 ± 2.1 to 5.5 ± 2.5 mm (P < 0.001). In the control group, the mean PD was reduced from

Fig. 2.30 Effect of an oily calcium hydroxide suspension (Osteoinductal) on healing of intrabony periodontal defects in dogs. (a) Histological view of specimen 1 following application of oily calcium hydroxide suspension (OHCS) showing peri-odontal regeneration (magnification ×1.25). (b) Higher magnifi-

cation of the regenerated area shown in a demonstrated formation of cementum, periodontal ligament and alveolar bone (magnifi-cation ×4) (Schwarz et al. 2006b) (Reprinted with permission from Springer)

1232.5 Composite Grafts

6.9 ± 0.9 to 3.7 ± 0.9 mm (P < 0.001) and the mean CAL changed from 8.5 ± 2.5 to 6.4 ± 2.7 mm (P < 0.001) (Stratul et al. 2006).

It has been also shown that the topical subgingival application of an oily calcium hydroxide suspension (Osteoinductal) after nonsurgical periodontal therapy improved early periodontal wound healing. The appli-cation of Osteoinductal resulted in significantly greater improvement in gingival and bleeding indices in exper-imental versus control sites at the 1-, 2- and 3-week examinations. In addition, no side effects like inflam-mation or pain were reported at sites subjected to Osteoinductal application (Kasaj et al. 2006).

2.4.9 Porous Titanium Granules

Recently, a non-resorbable, osteoconductive bone sub-stitute, was proposed to be used in stabilization of hip prostheses (Alffram et al. 2007; Turner et al. 2007), in connection with surgery of compression fractures in the lateral tibial plateau (Jónsson and Mjöberg 2009), in cases with large cystic cavities (Magistri et al. 2006), in patients planned for augmentation of the sinus floor prior to or in conjunction with placement of dental implants (Holmberg et al. 2008; Bystedt and Rasmusson 2009; Bystedt 2007) and in the surgical treatment of peri-implant osseous defects (Wohlfahrt et al. 2010c; Frei et al. 2010; Bergmann 2010).

Tigran™ PTG (Natix, Tigran Technologies AB, Malmö, Sweden) is irregularly shaped and porous gran-ules manufactured using commercially pure titanium. The granules are between 0.7 mm and 1.0 mm. When they are mixed with the patient’s blood or with a saline solution, the granules attach to each other due to the capillary force. The titanium surface is very throm-bogenic, which facilitates the formation of stabilizing blood clots around the granules. The granules that have a porosity of about 80% and an osteoconductive sur-face structure, imitate properties of human bone, and create a scaffolding for bone generation that stimulates osteoblast colonization and osseointegration. The gran-ules are non-resorbable and keep their volume dur-ing the operation and the entire healing period which ensures mechanical stability and a desired aesthetic result. Tigran™ PTG is easy to use. No special tools are needed. When osseointegration is completed, com-mon drilling techniques are used when an implant has to be placed in the treated area (http://www.tigran.se/

en/professional/products/tigrantm-ptg/). The titanium granules do not set (i.e., no risk of heat injury to the bone) and can therefore be handled without time pres-sure during surgery (Jónsson and Mjöberg 2009).

Tigran’s porous titanium granules have been demon-strated experimentally to have superior microstructural properties (porosity, interconnectivity, open pore size and surface area-to-volume ratio), cell viability and pro-liferation rate compared to both Straumann BoneCeramic and Geistlich Bio-Oss (Sabetrasekh et al. 2010).

Histological examination in an animal model revea-led, 6 months after implantation, lamellar bone formation through the mantle of porous titanium granules in continu-ity with the surrounding cortex resulting in the formation of an integrated mantle of bone and titanium granulate around the prosthesis (Turner et al. 2007). When used calibrated defects prepared in the tibias of New Zealand rabbits, both metallic and oxidized porous titanium gran-ules demonstrated osteoconductive proprieties that can be used to promote bone formation in osseous defects adjacent to titanium implants without hampering implant osseointegration (Wohlfahrt et al. 2010a). A randomized animal experiment has indicated that degree II furcation defects in minipigs grafted with PTG demonstrated sig-nificantly better osseous regeneration compared bovine hydroxyapatite (Bio-Oss) grafted defects. No significant signs of adverse events were seen in any of the treatment groups (Wohlfahrt et al. 2010b).

No randomized clinical trials are presently avail-able regarding the efficacy of porous titanium granules in the treatment of periodontal defects.

2.5 Composite Grafts

One of the most promising emerging surgical options may be the use of a “composite graft” that contains osteo-genic cells and osteoinductive growth factors along with a synthetic osteoconductive matrix. Com posite materials being tested in preclinical and clinical trials may exhibit functionality comparable to autograft and allograft. Composite synthetic grafts offer an alternative that can potentially unite the three essential bone-forming proper-ties in more controlled and effective combinations with-out the disadvantages found with autograft. A composite graft combines an osteoconductive matrix with bioac-tive agents that provide osteoinductive and osteogenic properties, potentially replicating autograft functionality. The osteoconductive matrix becomes a delivery system


for bioactive agents, requiring less chemotaxis and less migration of osteoblast progenitor cells to the graft site. The direct infusion of progenitor cells should lead to more rapid and consistent bone recovery. When an osteo-conductive scaffold is seeded with bone morphogenetic proteins, for example, the composite graft may become both osteogenic and osteoinductive, providing a competi-tive alternative to autograft (Giannoudis et al. 2005; De Long et al. 2007). Such potential composite grafts are: bone marrow/synthetic composites, ultraporous b-TCP/BMA composite, osteoinductive growth factors and synthetic composites, BMP/polyglycolic acid polymer-composites and BMA/BMP/polyglycolic acid polymer-composite (Giannoudis et al. 2005).

Some of the commercially available composite grafts that are commonly used are Healos® (Orquest, Mountain View, CA), Collagraft® (Zimmer Corp, Warsaw, IN)

and Tricos® (Baxter BioSciences BioSurgery) ceram-ics (Biomatlante manufacturer, Vigneux de Bretagne, France).

Limited clinical data exist on the use of composite grafts in the treatment of periodontal defects (Sanders et al. 1983; Sottosanti 1993; Sottosanti 1995; Anson 1996; Anson 1998; Harris 2004; Harris 1998; Orsini et al. 2001; Maragos et al. 2002; Okuda et al. 2005; Orsini et al. 2008). Alloplasts can be mixed with autog-enous grafts or allografts in the management of large structural defects (Zafiropoulos et al. 2007). It was suggested that a mixture of autogenous bone and these materials should be used to overcome the lack of osseoinductivity of xenografts and alloplastic materials and to reduce the amount of bone resorption observed with pure autogenous grafts (Figs. 2.31 and 2.32). Thorwarth et al. (2006) demonstrated an accelerating

a b

c d

DBBM 6 weeks

DBBM 6 weeks

DBBM + AB 6 weeks

DBBM + AB 6 weeks

DBBM

DBBM

bone

Fig. 2.31 De novo bone formation following application of autogenous bone to particulated anorganic bovine material in vivo. (a, b) Light microscopy at 6 weeks (toluidine blue O staining, magnification 35). (a) Group A = DBBM. (b) Group

B = DBBM 1.25% particulated AB. (c, d) Corresponding micro-radiographic images, enhanced de novo bone formation due to addition of particulated autogenous bone in group B (Thorwarth et al. 2006) (Reprinted with permission from Elsevier)

1252.6 Factors Impacting Treatment Outcome

effect of autogenous bone on bone formation in combi-nation with deproteinized bovine bone matrix. This effect is likely caused by osteoinductive properties of cellular elements transplanted with the autogenous bone. It was also concluded that 25% autogenous bone was a sufficient volume to meet this accelerating effect on bone formation (Thorwarth et al. 2006). In deep intrabony defects treatment, at 12 months evaluation, the combined use of autogenous spongiosa with bovine-derived xenograft or with HA/b-TCP led to signifi-cantly greater gain of clinical attachment and hard tissue formation compared to the use of autogenous spongiosa alone (Zafiropoulos et al. 2007).

In addition to these materials, research is continu-ing to modify the products with hopes of creating a graft that incorporates faster, resorbs and yields a bony union that resembles natural form and structure (Kuo et al. 2007).

2.6 Factors Impacting Treatment Outcome

2.6.1 Criteria for Evaluation of Graft Success for Periodontal Regeneration

For any graft material to be considered as a successful regenerative material, it should have clear histological, clinical and radiographic evidence of the following cri-teria (AlGhamdi et al. 2010a):

1. Biologic acceptability: the graft should not have any side effects or cause any unwanted tissue reaction.

2. Resorbability: the graft should resorb slowly and be replaced by the patient’s own bone.

a b

c d

DBBM 12 weeks

DBBM 12 weeks

DBBM + AB 12 weeks

DBBM + AB 12 weeks

DBBM

boneDBBM

bone

Fig. 2.32 De novo bone formation following application of autogenous bone to particulated anorganic bovine material in vivo. (a, b) Light microscopy at 12 weeks (toluidine blue O staining, magnification 35). (a) Group A = deproteinized bovine

bone matrix (DBBM). (b) Group B = DBBM + 25% particulated autogenous bone (AB). (c, d) Corresponding microradiographic images, adjustment of bone formation in both groups (Thorwarth et al. 2006) (Reprinted with permission from Elsevier)


3. Regeneration: the graft should have evidence of regenerative ability with formation of new bone, cementum and periodontal ligament fibers.

4. Defect fill: the graft should have evidence of bone fill.

5. Stability: the outcome of the treatment should be stable at reevaluation visits.

2.6.2 Factors Influencing Graft Success

Several studies have investigated the possible sources of variability in the clinical outcomes of bone graft-ing procedures in periodontal surgery: (1) the patient, (2) the morphology of the defect, (3) the graft mate-rial, (4) the surgical procedure and (5) the healing period (Cortellini and Tonetti 2000; AlGhamdi et al. 2010a).

2.6.2.1 Patient Factors

The scientific literature clearly shows that plaque con-trol (Cortellini et al. 1994), residual periodontal infec-tion, tobacco smoking (Tonetti et al. 1995) and the patient’s compliance (Wilson et al. 1984; Wilson et al. 1993b) are important prognostic factors in regenerative periodontal therapy. Other factors include conditions such as diabetes, hyperparathyroidism, thyrotoxicosis, osteomalacia, osteoporosis, Paget’s disease and some medications may all affect the healing process (AlGhamdi et al. 2010a).

2.6.2.2 The Morphology of the Defect

Among the defect anatomy-associated factors, depth of the intrabony component of the defect and/or prob-ing depth is consistently found to be relevant (Tonetti et al. 1996; Tonetti et al. 1998; Cortellini et al. 2001). The number of residual bony walls defining the defect seems to affect outcomes. Defects with two and three bony walls respond more favorably to treatment than do one-wall defects (Froum et al. 1976; Sepe et al. 1978). Also periodontal regeneration was more suc-cessful in deep-narrow defects than in shallow-wide defects (Dragoo and Sullivan 1973a; Froum et al. 1976; Mellonig 1984).

2.6.2.3 Selection of Graft Material

When bony reconstruction is presented to the surgeon, many choices must be weighed before the proper graft material is chosen (Kuo et al. 2007). Selection of graft material is guided by:

1. Biologic acceptability2. Predictability3. Resorbability4. Clinical feasibility5. Minimal operative hazards6. Minimal postoperative sequelae7. Patient acceptance (AlGhamdi et al. 2010a and ref-

erences therein)

A range of 125–1,000 mm is acceptable with 250–750 mm most commonly available for particle size of grafts used in periodontal treatment. A mini-mal pore size of 100 mm is needed between particles to allow vascularization and bone formation. Particles less than 100 mm in size elicit a macrophage response and are rapidly resorbed with little or no new bone formation (Zaner and Yukna 1984; AlGhamdi et al. 2010a).

2.6.2.4 The Surgical Procedure

The surgical technique for the treatment of periodontal intrabony defects with bone replacement grafts is essen-tially the same regardless of the type of graft material being used. Incisions are designed to allow for primary closure of flaps to protect the graft site from infection and the graft material from displacement. Intrasulcular incisions are the common choice, with emphasis on preserving interdental tissue. Flaps are reflected full thickness to expose the underlying osseous defects and allow access for thorough debridement of the defects and meticulous root planning (Hanes, 2007). New surgical techniques have been developed to optimize primary closure as well as to minimize the surgical trauma in the reconstructive procedures of periodontal intraosseous defects. Recently, we proposed a mini-mally invasive procedure, the single-flap approach (SFA), specifically indicated when the defect exten-sion is prevalent on the buccal or oral side. The basic principle of the SFA is the elevation of a flap to access the defect only on one side (buccal or oral), leaving the opposite side intact (Trombelli et al. 2009; Trombelli et al. 2010).

127References

Once the defect has been debrided of soft tissue and the tooth root surfaces thoroughly planed to remove all deposits of dental plaque and calculus, the bone replace-ment graft material is packed into the defect to fill the defect to the level of the remaining alveolar bone (Hanes, 2007). Space maintenance is paramount to bone forma-tion. If the graft material resorbs too rapidly, compared with the time required for bone formation, the site may fill with connective tissue rather than bone (AlGhamdi et al. 2010a). Therefore the space or contour and size of the augmentation should be maintained until the graft has formed enough bone to maintain the space itself (AlGhamdi et al. 2010a; Misch 1999; Polimeni et al. 2006). Absolute graft immobility is paramount to its union to the recipient bone. If pieces of bone graft are mobile, they cannot receive a blood supply, become encapsulated in fibrous tissue and often sequestrate (AlGhamdi et al. 2010a; Lin et al. 1990).

Flaps are closed and sutured for primary closure and complete coverage of the bone replacement graft (Hanes, 2007). Sutures should be removed in 7–10 days.

2.6.2.5 The Postsurgical Healing Period

Postsurgical care should include twice-daily rinsing with 0.12% chlorhexidine gluconate for 2 weeks and gentle toothbrushing starting 1 week after the surgery. Systemic antibiotics may be prescribed for 7–10 days after the sur-gical procedure. Patients should be seen at intervals of 1 week, 2 weeks and 4 weeks after surgery for suprag-ingival plaque removal and then should be placed on a periodontal maintenance schedule at 3-month intervals (Hanes, 2007).

Adequate healing time must be provided to allow regeneration of the new bone volume. The amount of time required is variable and depends on local factors such as the number of remaining walls of bone, the amount of autogenous bone in the graft and the size of the defect. Larger grafts, less autogenous bone in the graft and fewer bony walls increase the amount of healing time (AlGhamdi et al. 2010a; Misch and Dietsh 1993; Misch 1999).

References

Aichelmann-Reidy ME, Yukna RA (1998) Bone replacement grafts. The bone substitutes. Dent Clin North Am 42: 491–503

Aichelmann-Reidy ME, Heath CD, Reynolds MA (2004) Clinical evaluation of calcium sulfate in combination with demineralized freeze-dried bone allograft for the treatment of human intraosseous defects. J Periodontol 75:340–347

Al Ruhaimi KA (2001) Bone graft substitutes: a comparative qualitative histologic review of current osteoconductive graft-ing materials. Int J Oral Maxillofac Implants 16:105–114

Alffram PA, Bruce L, Bjursten LM, Urban RM, Andersson GB (2007) Implantation of the femoral stem into a bed of tita-nium granules using vibration: a pilot study of a new method for prosthetic fixation in 5 patients followed for up to 15 years. Ups J Med Sci 112:183–189

AlGhamdi AS, Shibly O, Ciancio SG (2010a) Osseous grafting part I: autografts and allografts for periodontal regeneration–a literature review. J Int Acad Periodontol 12:34–38

AlGhamdi AS, Shibly O, Ciancio SG (2010b) Osseous graft-ing part II: xenografts and alloplasts for periodontal regen-eration–a literature review. J Int Acad Periodontol 12: 39–44

Allan I, Newman H, Wilson M (2001) Antibacterial activity of particulate bioglass against supra- and subgingival bacteria. Biomaterials 22:1683–1687

Allan I, Newman H, Wilson M (2002) Particulate Bioglass reduces the viability of bacterial biofilms formed on its sur-face in an in vitro model. Clin Oral Implants Res 13:53–58

Altiere ET, Reeve CM, Sheridan PJ (1979) Lyophilized bone allografts in periodontal intraosseous defects. J Periodontol 50:510–519

Ambard AJ, Mueninghoff L (2006) Calcium phosphate cement: review of mechanical and biological properties. J Prosthodont 15:321–328

Anderegg CR, Alexander DC, Freidman M (1999) A bioactive glass particulate in the treatment of molar furcation inva-sions. J Periodontol 70:384–387

Annalisa P, Furio P, Ilaria Z, Anna A, Luca S, Marcella M, Marzia A, Elena M, Carinci F (2008) Anorganic bovine bone and a silicate-based synthetic bone activate different microRNAs. J Oral Sci 50:301–307

Anson D (1996) Calcium sulfate: a 4-year observation of its use as a resorbable barrier in guided tissue regeneration of peri-odontal defects. Compend Contin Educ Dent 17:895–899

Anson D (1998) Saving periodontally “hopeless teeth” using cal-cium sulfate and demineralized freeze-dried bone allograft. Compend Contin Educ Dent 19:284, 286, 288 passim

Aral A, Yalçin S, Karabuda ZC, Anil A, Jansen JA, Mutlu Z (2008) Injectable calcium phosphate cement as a graft mate-rial for maxillary sinus augmentation: an experimental pilot study. Clin Oral Implants Res 19:612–617

Arcuri C, Cecchetti F, Germano F, Motta A, Santacroce C (2005) Clinical and histological study of a xenogenic bone substi-tute used as a filler in postextractive alveolus. Minerva Stomatol 54:351–362

Artzi Z, Nemcovsky C (1998) The application of deproteinized bovine bone mineral for ridge preservation prior to implan-tation. Clinical and histological observations in a case report. J Periodontol 69:1062–1067

Artzi Z, Weinreb M, Givol N, Rohrer MD, Nemcovsky CE, Prasad HS, Tal H (2004) Biomaterial resorption rate and healing site morphology of inorganic bovine bone and beta-tricalcium phosphate in the canine: a 24-month longitudinal histologic study and morphometric analysis. Int J Oral Maxillofac Implants 19:357–368


Ashman A (1988) Applications of HTR polymer in dentistry. Compend Suppl (10):S330–S336

Ashman A (1992) The use of synthetic bone materials in den-tistry. Compendium 13(11):1020; 1022, 1024–1026

Ashman A, Moss LM (1977) Implantation of porous polym-ethylmethacrylate resin for tooth and bone replacement. J Prosthet Dent 37:657–665

Aspriello SD, Ferrante L, Rubini C, Piemontese M (2011) Comparative study of DFDBA in combination with enamel matrix derivative versus DFDBA alone for treatment of peri-odontal intrabony defects at 12 months post-surgery. Clin Oral Investig 15(2):225–232

Aybar B, Bilir A, Akçakaya H, Ceyhan T (2004) Effects of trical cium phosphate bone graft materials on primary cul-tures of osteoblast cells in vitro. Clin Oral Implants Res 15:119–125

Baldock WT, Hutchens LH Jr, McFall WT Jr, Simpson DM (1985) An evaluation of tricalcium phosphate implants in human periodontal osseous defects of two patients. J Periodontol 56:1–7

Bannister SR, Powell CA (2008) Foreign body reaction to anorga nic bovine bone and autogenous bone with platelet-rich plasma in guided bone regeneration. J Periodontol 79: 1116–1120

Barnett JD, Mellonig JT, Gray JL, Towle HJ (1989) Comparison of freeze-dried bone allograft and porous hydroxylapatite in human periodontal defects. J Periodontol 60:231–237

Barney VC, Levin MP, Adams DF (1986) Bioceramic implants in surgical periodontal defects. A comparison study. J Periodontol 57:764–770

Barone A, Ricci M, Covani U, Nannmark U, Azarmehr I, Calvo-Guirado JL (2010) Maxillary sinus augmentation using pre-hydrated corticocancellous porcine bone: hystomorphometric evaluation after 6 months. Clin Implant Dent Relat Res [Epub ahead of print]

Beckham CH, Greenlee J, Crebo AR (1971) Bone formation at a ceramic implant surface. Calcif Tissue Res 8:165–171

Beertsen W, van den Bos T, Niehof J (1993) Mineralization of dentinal collagen sheets complexed with alkaline phos-phatase and integration with newly formed bone following subperiosteal implantation over osseous defects in rat calva-ria. Bone Miner 20:41–55

Bell WH (1964) Resorption rates of bone and bone substitutes. Oral Surg 17:650–657

Beloti MM, Martins W Jr, Xavier SP, Rosa AL (2008) In vitro osteogenesis induced by cells derived from sites submitted to sinus grafting with anorganic bovine bone. Clin Oral Implants Res 19:48–54

Bender SA, Rogalski JB, Mills MP, Arnold RM, Cochran DL, Mellonig JT (2005) Evaluation of demineralized bone matrix paste and putty in periodontal intraosseous defects. J Periodontol 76:768–777

Benke D, Olah A, Möhler H (2001) Protein-chemical analysis of Bio-Oss bone substitute and evidence on its carbonate con-tent. Biomaterials 22:1005–1012

Benqué EP, Gineste M, Heughebaert M (1985) Histological study of the biocompatibility of hydroxyapatite crystals in periodontal surgery. J Biol Buccale 13:271–282

Berglundh T, Lindhe J (1997) Healing around implants placed in bone defects treated with Bio-Oss. An experimental study in the dog. Clin Oral Implants Res 8:117–124

Bergmann F (2010) Ein neues Konzept bei Periimplantitis. Vorgehen mittels aPDT und knochenregenerativ augmenta-tiven Maßnahmen [A new concept within peri-implantitis. Approach by means of aPDT and bone regenerative aug-mentation]. Implantologie Journal 14:36–39

Blay A, Tunchel S, Sendyk WR (2003) Viability of autogenous bone grafts obtained by using bone collectors: histological and microbiological study. Pesqui Odontol Bras 17:234–240

Blokhuis TJ, Lindner T (2008) Allograft and bone morphoge-netic proteins: an overview. Injury 39(Suppl 2):S33–S36

Blom EJ, Klein-Nulend J, Yin L, van Waas MA, Burger EH (2001) Transforming growth factor-beta1 incorporated in calcium phosphate cement stimulates osteotransductivity in rat calvarial bone defects. Clin Oral Implants Res 12(6):609–616

Blumenthal N, Steinberg J (1990) The use of collagen mem-brane barriers in conjunction with combined demineralized bone-collagen gel implants in human infrabony defects. J Periodontol 61:319–327

Bohner M, Lemaitre J, Van Landuyt P, Zambelli PY, Merkle HP, Gander B (1997) Gentamicin-loaded hydraulic cal-cium phosphate bone cement as antibiotic delivery system. J Pharm Sci 86:565–572

Bohner M, Gbureck U, Barralet JE (2005) Technological issues for the development of more efficient calcium phosphate bone cements: a critical assessment. Biomaterials 26(33): 6423–6429

Bokan I, Bill JS, Schlagenhauf U (2006) Primary flap closure combined with Emdogain® alone or Emdogain® and Cerasorb® in the treatment of intra-bony defects. J Clin Periodontol 33:885–893

Borghetti A, Novakovitch G, Louise F, Simeone D, Fourel J (1993) Cryopreserved cancellous bone allograft in periodon-tal intraosseous defects. J Periodontol 64(2):128–132

Bornstein MM, Chappuis V, von Arx T, Buser D (2008) Performance of dental implants after staged sinus floor elevation procedures: 5-year results of a prospective study in partially edentulous patients. Clin Oral Implants Res 19: 1034–1043

Bosshardt DD, Sculean A (2009) Does periodontal tissue regen-eration really work? Periodontol 2000 51:208–219

Bowen JA, Mellonig JT, Gray JL, Towle HT (1989) Comparison of decalcified freeze-dried bone allograft and porous partic-ulate hydroxyapatite in human periodontal osseous defects. J Periodontol 60:647–654

Bowers GM, Chadroff B, Carnevale R et al (1989a) Histologic evaluation of new attachment apparatus formation in humans. Part III. J Periodontol 60:683

Bowers GM, Chadroff B, Carnevale R, Mellonig J, Corio R, Emerson J, Stevens M, Romberg E (1989b) Histologic eval-uation of new attachment apparatus formation in humans. Part II. J Periodontol 60:675–682

Bowers GM, Chadroff B, Carnevale R, Mellonig J, Corio R, Emerson J, Stevens M, Romberg E (1989c) Histologic eval-uation of new attachment apparatus formation in humans. Part III. J Periodontol 60:683–693

Bowers G, Felton F, Middleton C et al (1991) Histologic compar-ison of regeneration in human intrabony defects when osteo-genin is combined with demineralized freeze-dried bone allograft and with purified bovine collagen. J Periodontol 62:690

129References

Bowers GM, Schallhorn RG, McClain PK, Morrison GM, Morgan R, Reynolds MA (2003) Factors influencing the out-come of regenerative therapy in mandibular Class II furca-tions: Part I. J Periodontol 74:1255–1268

Boyan BD, Weesner TC, Lohmann CH, Andreacchio D, Carnes DL, Dean DD, Cochran DL, Schwartz Z (2000) Porcine fetal enamel matrix derivative enhances bone formation induced by demineralized freeze dried bone allograft in vivo. J Periodontol 71:1278–1286

Boyan BD, Ranly DM, Schwartz Z (2006) Use of growth factors to modify osteoinductivity of demineralized bone allografts: lessons for tissue engineering of bone. Dent Clin North Am 50:217–228

Browaeys H, Bouvry P, De Bruyn H (2007) A literature review on biomaterials in sinusmentation procedures. Clin Implant Dent Relat Res 9:166–177

Brown GD, Mealey BL, Nummikoski PV, Bifano SL, Waldrop TC (1998) Hydroxyapatite cement implant for regeneration of periodontal osseous defects in humans. J Periodontol 69: 146–157

Burguera EF, Xu HH, Sun L (2008) Injectable calcium phos-phate cement: effects of powder-to-liquid ratio and needle size. J Biomed Mater Res B Appl Biomater 84:493–502

Bystedt H (2007) Natix used as osteoconductive material for sinus floor augmentation. Three years follow-up. Case report. Presented at the 44th Annual Congress of the Swedish Dental Society, November 8–10, 2007, Göteborg, Sweden. Swed Dent J 31:193

Bystedt H, Rasmusson L (2009) Porous titanium granules used as osteoconductive material for sinus floor augmen-tation: a clinical pilot study. Clin Implant Dent Relat Res 11:101–105

Callan DP, Rohrer MD (1993) Use of bovine-derived hydroxyap-atite in the treatment of edentulous ridge defects: a human cli-nical and histologic case report. J Periodontol 64(6):575–582

Calongne KB, Aichelmann-Reidy ME, Yukna RA, Mayer ET (2001) Clinical comparison of microporous biocompatible composite of PMMA. PHEMA and calcium hydroxide grafts and expanded polytetrafluoroethylene barrier membranes in human mandibular molar Class II furcations. A case series. J Periodontol 72(10):1451–1459

Calvo Guirado JL, Ramírez Fernández MP, Negri B, Delgado Ruiz RA, Maté Sánchez de-Val JE, Gómez-Moreno G (2011) Experimental model of bone response to collagenized xeno-grafts of porcine origin (OsteoBiol® mp3): a radiological and histomorphometric study. Clin Implant Dent Relat Res. doi:doi: 10.1111/j.1708-8208.2011.00337.x; (Epub ahead of print)

Camargo PM, Lekovic V, Weinlaender M, Nedic M, Vasilic N, Wolinsky LE, Kenney EB (2000) A controlled re-entry study on the effectiveness of bovine porous bone mineral used in combination with a collagen membrane of porcine origin in the treatment of intrabony defects in humans. J Clin Periodontol 27:889–896

Camelo M, Nevins M, Schenk R, Simion M, Rasperini G, Lynch S, Nevins M (1998) Clinical, radiographic, and histologic evaluation of human periodontal defects treated with Biooss and Bio-Gide. Int J Periodontics Restorative Dent 18: 321–331

Camelo M, Nevins ML, Lynch SE, Schenk RK, Simion M, Nevins M (2001) Periodontal regeneration with an autog-

enous bone-Bio-Oss composite graft and a Bio-Gide membrane. Int J Periodontics Restorative Dent 21: 109–119

Camelo M, Nevins ML, Schenk RK, Lynch SE, Nevins M (2003) Periodontal regeneration in human Class II furcations using purified recombinant human platelet-derived growth factor-BB (rhPDGF-BB) with bone allograft. Int J Periodontics Restorative Dent 23:213–225

Cardaropoli G, Araújo M, Hayacibara R, Sukekava F, Lindhe J (2005) Healing of extraction sockets and surgically pro-duced – augmented and non-augmented - defects in the alveolar ridge. An experimental study in the dog. J Clin Periodontol 32:435–440

Carinci F, Palmieri A, Martinelli M, Perrotti V, Piattelli A, Brunelli G, Arlotti M, Pezzetti F (2007) Genetic portrait of osteoblast-like cells cultured on PerioGlas. J Oral Implantol 33(6):327–333

Carranza FA Jr, Kenney EB, Lekovic V, Talamante E, Valencia J, Dimitrijevic B (1987) Histologic study of healing of human periodontal defects after placement of porous hydroxylapatite implants. J Periodontol 58:682–688

Carvalho VA, Tosello Dde O, Salgado MA, Gomes MF (2004) Histomorphometric analysis of homogenous demineralized dentin matrix as osteopromotive material in rabbit mandi-bles. Int J Oral Maxillofac Implants 19(5):679–686

Centers for Disease Control and Prevention (2010) Bone allografts. What is the risk of disease transmission with bone allografts? In: Department of Health and Human Services. Available at: http://www.cd.gov/OralHealth/Infectioncontrol/faq/allografts.htm. Accessed 19 Oct 2010

Chen CC, Wang HL, Smith F, Glickman GN, Shyr Y, O’Neal RB (1995) Evaluation of a collagen membrane with and without bone grafts in treating periodontal intrabony defects. J Periodontol 66(10):838–847

Chen FM, Zhang J, Zhang M, An Y, Chen F, Wu ZF (2010) A review on endogenous regenerative technology in perio dontal regenerative medicine. Biomaterials 31(31): 7892–7927

Chiang YC, Chen HJ, Liu HC, Kang SH, Lee BS, Lin FH, Lin HP, Lin CP (2010) A novel mesoporous biomaterial for treating dentin hypersensitivity. J Dent Res 89:236–240

Chiriac G, Herten M, Schwarz F, Rothamel D, Becker J (2005) Autogenous bone chips: influence of a new piezoelectric device (Piezosurgery) on chip morphology, cell viability and differentiation. J Clin Periodontol 32:994–999

Choi JY, Jung UW, Lee IS, Kim CS, Lee YK, Choi SH (2011) Resolution of surgically created three-wall intrabony defects in implants using three different biomaterials: an in vivo study. Clin Oral Implants Res 22(3):343–348.

Chris Arts JJ, Verdonschot N, Schreurs BW, Buma P (2006) The use of a bioresorbable nano-crystalline hydroxyapatite paste in acetabular bone impaction grafting. Biomaterials 27: 1110–1118

Christgau M, Moder D, Hiller K-A, Dada A, Schmitz G, Schmalz G (2006) Growth factors and cytokines in autologous plate-let concentrate and their correlation to periodontal regenera-tion outcomes. J Clin Periodontol 33:837–845

Cochran DL, Jones A, Heijl L, Mellonig JT, Schoolfield J, King GN (2003) Periodontal regeneration with a combination of enamel matrix proteins and autogenous bone grafting. J Periodontol 74:1269–1281


Cohen MS, Whitman K (1997) Calcium phosphate bone cement: The Norian skeletal repair system in orthopedic surgery. AORN J 65:958–962

Cohen RE, Mullarky RH, Noble B, Comeau RL, Neiders ME (1994) Phenotypic characterization of mononuclear cells following anorganic bovine bone implantation in rats. J Periodontol 65:1008–1015

Committee on Research, Science and Therapy of the American Academy of Periodontology (2001) Tissue banking of bone allografts used in periodontal regeneration. J Periodontol 72:834–838

Comuzzi L, Ooms E, Jansen JA (2002) Injectable calcium phos-phate cement as a filler for bone defects around oral implants: an experimental study in goats. Clin Oral Implants Res 13:304–311

Constantz BR, Ison IC, Fulmer MT et al (1995) Skeletal repair by in situ formation of the mineral phase of bone. Science 267:1796–1799

Cortellini P, Pini Prato G, Tonetti MS (1994) Periodontal regen-eration of human infrabony defects. V. Effect of oral hygiene on long term stability. J Clin Periodontol 21:606–610

Cortellini P, Tonetti MS (2000) Focus on intrabony defects: guided tissue regeneration. Periodontol 22:104–132

Cortellini P, Tonetti M, Lang NP et al (2001) The simplified papilla preservation flap in the regenerative treatment of deep intrabony defects: clinical outcomes and postoperative morbidity. J Periodontol 72:1702–1712

Cortellini P, Nieri M, Prato GP, Tonetti MS (2008) Single mini-mally invasive surgical technique with an enamel matrix derivative to treat multiple adjacent intra-bony defects: clini-cal outcomes and patient morbidity. J Clin Periodontol 35:605–613

Couri CJ, Maze GI, Hinkson DW, Collins BH 3rd, Dawson DV (2002) Medical grade calcium sulfate hemihydrate versus expanded polytetrafluoroethylene in the treatment of man-dibular class II furcations. J Periodontol 73:1352–1359

Curtis AR, West NX, Su B (2010) Synthesis of nanobioglass and formation of apatite rods to occlude exposed dentine tubules and eliminate hypersensitivity. Acta Biomater 6: 3740–3746

Czuryszkiewicz-Cyrana J, Banach J (2006) Autogenous bone and platelet-rich plasma (PRP) in the treatment of intrabony defects. Adv Med Sci 51(Suppl 1):26–30

Damien E, Revell PA (2004) Coralline hydroxyapatite bone graft substitute: a review of experimental studies and bio-medical applications. J Appl Biomater Biomech 2:65–73

Danesh-Meyer MJ, Filstein MR, Shanaman R (2001) Histological evaluation of sinusmentation using platelet rich plasma (PRP): a case series. J Int Acad Periodontol 3:48–56

Jr De Long WG, Einhorn TA, Koval K, McKee M, Smith W, Sanders R, Watson T (2007) Bone grafts and bone graft sub-stitutes in orthopaedic trauma surgery: a critical analysis. J Bone Joint Surg Am 89:649–658

De Putter C, De Groot K, Sillevis-Smith PAE (1983) Transmucosal implants of dense hydroxyapatite. J Prosthet Dent 49:87–95

Demers C, Hamdy CR, Corsi K, Chellat F, Tabrizian M, Yahia L (2002) Natural coral exoskeleton as a bone graft substitute: a review. Biomed Mater Eng 12:15–35

Demir B, Demiralp B, Güncü GN, Uyanik MO, Ca∅layan F (2007a) Intentional replantation of a hopeless tooth with the

combination of platelet rich plasma, bioactive glass graft material and non-resorbable membrane: a case report. Dent Traumatol 23:190–194

Demir B, Sengün D, Berbero∅lu A (2007b) Clinical evaluation of platelet-rich plasma and bioactive glass in the treatment of intra-bony defects. J Clin Periodontol 34:709–715

Dereka XE, Markopoulou CE, Mamalis A, Pepelassi E, Vrotsos IA (2006) Time- and dose-dependent mitogenic effect of basic fibroblast growth factor combined with different bone graft materials: an in vitro study. Clin Oral Implants Res 17:554–559

Dereka XE, Markopoulou CE, Mamalis A, Vrotsos IA (2009) Effect of rhBMP-7 combined with two bone grafts on human periodontal ligament cell differentiation. Growth Factors 27:274–279

Detienville R, Mirot F, Triller C (1986) Clinical study of a bioresorbable ceramic (Synthograft) in the treatment of intraosseous lesions. 2. Clinical results after 1 year. J Parodontol 5:103–110

Develioglu H, Saraydin SU, Bolayir G, Dupoirieux L (2006) Assessment of the effect of a biphasic ceramic on bone response in a rat calvarial defect model. J Biomed Mater Res A 77:627–631

DiBattista P, Bissada NF, Ricchetti PA (1995) Comparative effec-tiveness of various regenerative modalities for the treatment of localized juvenile periodontitis. J Periodontol 66:673–678

Diem CR, Bowers GM, Moffitt WC (1972) Bone blending: a technique for bone implantation. J Periodontol 43:295–297

Dietrich T, Zunker P, Dietrich D, Bernimoulin JP (2003) Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: results after 12 months. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 95:474–482

Döri F, Huszár T, Nikolidakis D, Tihanyi D, Horváth A, Arweiler NB, Gera I, Sculean A (2008) Effect of platelet-rich plasma on the healing of intrabony defects treated with Beta trical-cium phosphate and expanded polytetrafluoroethylene mem-branes. J Periodontol 79:660–669

Dragoo MR, Kaldahl WB (1983) Clinical and histological eval-uation of alloplasts and allografts in regenerative periodontal surgery in humans. Int J Periodontics Restorative Dent 3:8–29

Dragoo MR, Sullivan HC (1973a) A clinical and histological evaluation of autogenous iliac bone grafts in humans. I. Wound healing 2 to 8 months. J Periodontol 44:599–613

Dragoo MR, Sullivan HC (1973b) A clinical and histological evaluation of autogenous iliac bone grafts in humans. II. External root resorption. J Periodontol 44:614–625

Drury GI, Yukna RA (1991) Histologic evaluation of combining tetracycline and allogeneic freeze-dried bone on bone regen-eration in experimental defects in baboons. J Periodontol 62:652–658

Duval BT, Maynard JG, Gunsolley JC, Waldrop TC (2000) Treatment of human mucogingival defects utilizing a bioab-sorbable membrane with and without a demineralized freeze-dried bone allograft. J Periodontol 71:1687–1692

Dybvik T, Leknes KN, Bøe OE, Skavland RJ, Albandar JM (2007) Bioactive ceramic filler in the treatment of severe osseous defects: 12-month results. J Periodontol 78:403–410

Elder S, Frankenburg E, Goulet J, Yetkinler D, Poser R, Goldstein S (2000) Biomechanical evaluation of calcium phosphate

131References

cement-augmented fixation of unstable intertrochanteric fractures. J Orthop Trauma 14:386–393

Elkins AD, Jones LP (1988) The effects of plaster and autoge-nous cancellous bone on the healing of cortical defects in the femurs of dogs. Vet Surg 17:71–76

Ellinger RF, Nery EB, Lynch KL (1986) Histological assess-ment of periodontal osseous defects following implantation of hydroxyapatite and biphasic calcium phosphate ceramics: a case report. Int J Periodontics Restorative Dent 6:22–33

Eppley BL, Pietrzak WS, Blanton MW (2005) Allograft and alloplastic bone substitutes: a review of science and technol-ogy for the craniomaxillofacial surgeon. J Craniofac Surg 16(6):981–989

Espanol M, Perez RA, Montufar EB, Marichal C, Sacco A, Ginebra MP (2009) Intrinsic porosity of calcium phosphate cements and its significance for drug delivery and tissue engineering applications. Acta Biomater 5:2752–2762

Esposito M, Coulthard P, Worthington HV (2003) Enamel matrix derivative (Emdogain) for periodontal tissue regen-eration in intrabony defects (Cochrane Review). Cochrane Database Syst Rev (2):CD003875

Esposito M, Grusovin MG, Coulthard P, Worthington HV (2006) The efficacy of various bone augmentation procedures for dental implants: a Cochrane systematic review of random-ized controlled clinical trials. Int J Oral Maxillofac Implants 21:696–710

Esposito M, Grusovin MG, Coulthard P, Worthington HV (2008) The efficacy of interventions to treat peri-implantitis: a Cochrane systematic review of randomised controlled clini-cal trials. Eur J Oral Implantol 1:111–125

Evans GH, Yukna RA, Sepe WW, Mabry TW, Mayer ET (1989) Effect of various graft materials with tetracycline in local-ized juvenile periodontitis. J Periodontol 60:491–497

Ewers R, Goriwoda W, Schopper C, Moser D, Spassova E (2004) Histologic findings at augmented bone areas supplied with two different bone substitute materials combine with sinus floor lifting. Report of one case. Clin Oral Implants Res 15:96–100

Fagan MC, Owens H, Smaha J, Kao RT (2008) Simultaneous hard and soft tissue augmentation for implants in the esthetic zone: report of 37 consecutive cases. J Periodontol 79:1782–1788

FDA (2010a) http://www.accessdata.fda.gov/cdrh_docs/pdf4/k040278.pdf. Accessed 22 Oct 2010

FDA (2010b) http://www.accessdata.fda.gov/cdrh_docs/pdf3/k031073.pdf. Accessed 22 Oct 2010

FDA (2010c) http://www.accessdata.fda.gov/cdrh_docs/pdf/k003457.pdf. Accessed 22 Oct 2010

FDA (2010d) http://www.accessdata.fda.gov/cdrh_docs/pdf4/k040980.pdf. Accessed 22 Oct 2010

FDA (2010e) http://www.accessdata.fda.gov/cdrh_docs/pdf4/K042730.pdf. Accessed 22 Oct 2010

Feng JQ, Luan X, Wallace J, Jing D, Ohshima T, Kulkarni AB, D’Souza RN, Kozak CA, MacDougall M (1998) Genomic organization, chromosomal mapping, and promoter analysis of the mouse dentin sialophosphoprotein (Dspp) gene, which codes for both dentin sialoprotein and dentin phosphopro-tein. J Biol Chem 273:9457–9464

Fernández MR, Guirado JL, Ruiz RA, Sánchez de-Val JE, Ortega VV, Olmos LM (2011) Bone response to hydroxy-apatites with open porosity of animal origin (porcine

[OsteoBiol(®) mp3] and bovine [Endobon(®) ]): a radio-logical and histomorphometric study. Clin Oral Implants Res. doi:doi: 10.1111/j.1600-0501.2010.02058.x; (Epub ahead of print)

Figueiredo M, Henriques J, Martins G, Guerra F, Judas F, Figueiredo H (2010) Physicochemical characterization of biomaterials commonly used in dentistry as bone substi-tutes–comparison with human bone. J Biomed Mater Res B Appl Biomater 92(2):409–419

Flemmig TF, Ehmke B, Bolz K, Kübler NR, Karch H, Reuther J, Klaiber B (1998) Long-term maintenance of alveolar bone gain after implantation of autolyzed, antigen extracted, allo-genic bone in periodontal intraosseous defects. J Periodontol 69:47–53

Francis J, Brunsvold M, Prewett A, Mellonig J (1995) Clinical evaluation of an allogeneic bone matrix in the treatment of periodontal osseous defects. J Periodontol 66:1074–1079

Frei B, Steveling H, Mertens C (2010) Porous titanium granules for bone regeneration in peri-implantitis-related defects. Presented at the 19th Annual Scientific Meeting of the European Association for Osseointegration, October 6–9, 2010, Glasgow, United Kingdom. Clin Oral Implants Res 21:1146

Froum SJ (1996) Human histologic evaluation of HTR polymer and freeze-dried bone allograft. A case report. J Clin Periodontol 23:615–620

Froum S, Stahl SS (1987) Human intraosseous healing responses to the placement of tricalcium phosphate ceramic implants. II. 13 to 18 months. J Periodontol 58:103–109

Froum SJ, Thaler R, Scopp IW, Stahl SS (1975a) Osseous autografts. I. Clinical responses to bone blend or hip marrow grafts. J Periodontol 46:515–521

Froum SJ, Thaler R, Scopp IW, Stahl SS (1975b) Osseous autografts. II. Histological responses to osseous coagulum-bone blend grafts. J Periodontol 46:656–661

Froum SJ, Ortiz M, Witkin RT, Thaler R, Scopp IW, Stahl SS (1976) Osseous autografts. III. Comparison of osseous coag-ulum-bone blend implants with open curettage. J Periodontol 47:287–294

Froum SJ, Kushner L, Scopp IW, Stahl SS (1982) Human clinical and histologic responses to Durapatite implants in intraosseous lesions. Case reports. J Periodontol 53:719–725

Froum SJ, Kushner L, Stahl SS (1983) Healing responses of human intraosseous lesions following the use of debride-ment, grafting and citric acid root treatment. I. Clinical and histologic observations six months postsurgery. J Periodontol 54:67–76

Froum SJ, Weinberg MA, Tarnow D (1998) Comparison of bio-active glass synthetic bone graft particles and open debride-ment in the treatment of human periodontal defects. A clinical study. J Periodontol 69:698–709

Fujikawa K, Sugawara A, Murai S, Nishiyama M, Takagi S, Chow LC (1995) Histopathological reaction of calcium phosphate cement in periodontal bone defect. Dent Mater J 14:45–57

Furusawa T, Mizunuma K, Yamashita S, Takahashi T (1998) Investigation of early bone formation using resorbable bio-active glass in the rat mandible. Int J Oral Maxillofac Implants 13:672–676

Galgut PN, Waite IM, Bookshaw JD, Kingston CP (1992) A 4-year controlled clinical study into the use of a


ceramic hydroxylapatite implant material for the treat-ment of periodontal bone defects. J Clin Periodontol 19:570–577

Gao TJ, Tuominen TK, Lindholm TS, Kommonen B, Lindholm TC (1997) Morphological and biomechanical difference in healing in segmental tibial defects implanted with Biocoral or tricalcium phosphate cylinders. Biomaterials 18:219–223

Gauthier O, Boix D, Grimandi G, Aguado E, Bouler JM, Weiss P, Daculsi G (1999) A new injectable calcium phosphate biomaterial for immediate bone filling of extraction sockets: a preliminary study in dogs. J Periodontol 70:375–383

Giannoudis PV, Dinopoulos H, Tsiridis E (2005) Bone substi-tutes: an update. Injury 36(Suppl 3):S20–S27

Ginebra MP, Traykova T, Planell JA (2006a) Calcium phosphate cements as bone drug delivery systems: a review. J Control Release 113:102–110

Ginebra MP, Traykova T, Planell JA (2006b) Calcium phosphate cements: competitive drug carriers for the musculoskeletal system? Biomaterials 27:2171–2177

Gomes MF, dos Anjos MJ, Nogueira TO, Guimarães SA (2001) Histologic evaluation of the osteoinductive property of autogenous demineralized dentin matrix on surgical bone defects in rabbit skulls using human amniotic membrane for guided bone regeneration. Int J Oral Maxillofac Implants 16:563–571

Govindaraj S, Costantino PD, Friedman CD (1999) Current use of bone substitutes in maxillofacial surgery. Facial Plast Surg 15:73–81, Review

Graziani F, Cei S, Ivanovski S, La Ferla F, Gabriele M (2007) A systematic review of the effectiveness of bone collectors. Int J Oral Maxillofac Implants 22:729–735

Gross JS (1997) Bone grafting materials for dental applications: a practical guide. Compend Contin Educ Dent 18:1013–1020

Guida L, Annunziata M, Belardo S, Farina R, Scabbia A, Trombelli L (2007) Effect of autogenous cortical bone par-ticulate in conjunction with enamel matrix derivative in the treatment of periodontal intraosseous defects. J Periodontol 78:231–238

Guillemin G, Meunier A, Dallant P, Christel P, Pouliquen JC, Sedel L (1989) Comparison of coral resorption and bone apposition with two natural corals of different porosities. J Biomed Mater Res 23:765–779

Gupta R, Pandit N, Malik R, Sood S (2007) Clinical and radio-logical evaluation of an osseous xenograft for the treatment of infrabony defects. J Can Dent Assoc 73:513

Gurinsky BS, Mills MP, Mellonig JT (2004) Clinical evaluation of demineralized freeze-dried bone allograft and enamel matrix derivative versus enamel matrix derivative alone for the treatment of periodontal osseous defects in humans. J Periodontol 75:1309–1318

Haimi S, Suuriniemi N, Haaparanta AM, Ellä V, Lindroos B, Huhtala H, Räty S, Kuokkanen H, Sándor GK, Kellomäki M, Miettinen S, Suuronen R (2009) Growth and osteogenic differentiation of adipose stem cells on PLA/bioactive glass and PLA/beta-TCP scaffolds. Tissue Eng A 15:1473–1480

Hallman M, Thor A (2008) Bone substitutes and growth factors as an alternative/complement to autogenous bone for graft-ing in implant dentistry. Periodontol 2000 47:172–192

Hallman M, Lundgren S, Sennerby L (2001) Histologic analy-sis of clinical biopsies taken 6 months and 3 years after maxillary sinus floor augmentation with 80% bovine

hydroxyapatite and 20% autogenous bone mixed with fibrin glue. Clin Implant Dent Relat Res 3:87–96

Hämmerle CH, Chiantella GC, Karring T, Lang NP (1998) The effect of a deproteinized bovine bone mineral on bone regen-eration around titanium dental implants. Clin Oral Implants Res 9:151–162

Handschel J, Simonowska M, Naujoks C, Depprich RA, Ommerborn MA, Meyer U, Kübler NR (2009) A histomor-phometric meta-analysis of sinus elevation with various grafting materials. Head Face Med 5:12

Hanes PJ (2007) Bone replacement grafts for the treatment of periodontal intrabony defects. Oral Maxillofac Surg Clin North Am 19(4):499–512

Haris AG, Szabo G, Ashman A, Divinyi T, Suba Z, Martonffy K (1998) Five-year 224-patient prospective histological study of clinical applications using a synthetic bone alloplast. Implant Dent 7:287–299

Harris RJ (1998) A clinical evaluation of an allograft combined with a bioabsorbable membrane versus an alloplast/allograft composite graft combined with a bioabsorbable mem-brane. 100 consecutively treated cases. J Periodontol 69: 536–546

Harris RJ (2004) Clinical evaluation of a composite bone graft with a calcium sulfate barrier. J Periodontol 75:685–692

Harris RJ, Harris LE, Harris CR, Harris AJ (2007) Clinical eval-uation of a combined regenerative technique with enamel matrix derivative, bone grafts, and guided tissue regenera-tion. Int J Periodontics Restorative Dent 27:171–179

Hashimoto K (1983) Fundamental studies on plaster implants used for infrabony pockets, with special reference to the application of Plaster of Paris (paste type) in experi-mental bone defects. Nippon Shishubyo Gakkai Kaishi 25:44–65

Hashimoto-Uoshima M, Ishikawa I, Kinoshita A, Weng HT, Oda S (1995) Clinical and histologic observation of replace-ment of biphasic calcium phosphate by bone tissue in mon-keys. Int J Periodontics Restorative Dent 15:205–213

Hattar S, Asselin A, Greenspan D, Oboeuf M, Berdal A, Sautier JM (2005) Potential of biomimetic surfaces to promote in vitro osteoblast-like cell differentiation. Biomaterials 26(8):839–848

Hayashi C, Kinoshita A, Oda S, Mizutani K, Shirakata Y, Ishikawa I (2006) Injectable calcium phosphate bone cement provides favorable space and a scaffold for periodontal regeneration in dogs. J Periodontol 77:940–946

Heinz B, Kasaj A, Teich M, Jepsen S (2010) Clinical effects of nanocrystalline hydroxyapatite paste in the treatment of intrabony periodontal defects: a randomized controlled clin-ical study. Clin Oral Investig 14(5):525–531

Hench LL (2006) The story of Bioglass. J Mater Sci Mater Med 17:967–978

Hench LL, Splinter RJ, Allen WC, Greenlee TK (1971) Bonding mechanism at the interface of ceramic prosthetic materials: Part 1. J Biomed Mater Res Symp 2:117–141

Herold RW, Pashley DH, Cuenin MF, Niagro F, Hokett SD, Peacock ME, Mailhot J, Borke J (2002) The effects of vary-ing degrees of allograft decalcification on cultured porcine osteoclast cells. J Periodontol 73:213–219

Hiatt WH, Schallhorn RG (1973) Intraoral transplants of cancel-lous bone and marrow in periodontal lesions. J Periodontol 44:194–208

133References

Hogset O, Bredberg G (1986) Plaster of Paris: thermal proper-ties and biocompatibility. A study on an alternative implant material for ear surgery. Acta Otolaryngol (Stockh) 101: 445–452

Hoidal MJ, Grimard BA, Mills MP, Schoolfield JD, Mellonig JT, Mealey BL (2008) Clinical evaluation of demineralized freeze-dried bone allograft with and without enamel matrix derivative for the treatment of periodontal osseous defects in humans. J Periodontol 79:2273–2280

Holmberg L, Forsgren L, Kristerson L (2008) Porous titanium granules for implant stability and bone regeneration - a case followed for 12 years. Ups J Med Sci 113:217–220

Holtzclaw D, Toscano N, Eisenlohr L et al (2008) The safety of bone allografts used in dentistry: a review. J Am Dent Assoc 139:1192–1199

Hönig JF, Merten HA, Heinemann DE (1999) Risk of transmis-sion of agents associated with Creutzfeldt-Jakob disease and bovine spongiform encephalopathy. Plast Reconstr Surg 103:1324–1325

Horvath A, Stavropoulos A, Sculean A (2009) Clinical and his-tological evaluation of human intrabony periodontal defects treated with an unsintered nanocrystalline hydroxyapatite paste (Ostim®). J Clin Periodontol 36:116

Hu S, Chang J, Liu M, Ning C (2009) Study on antibacterial effect of 45 S5 Bioglass. J Mater Sci Mater Med 20:281–286

Huber FX, Belyaev O, Hillmeier J, Kock HJ, Huber C, Meeder PJ, Berger I (2006) First histological observations on the incorpo-ration of a novel nanocrystalline hydroxyapatite paste OSTIM in human cancellous bone. BMC Musculoskelet Disord 7:50

Huber FX, Berger I, McArthur N, Huber C, Kock HP, Hillmeier J, Meeder PJ (2008) Evaluation of a novel nanocrystalline hydroxyapatite paste and a solid hydroxyapatite ceramic for the treatment of critical size bone defects (CSD) in rabbits. J Mater Sci Mater Med 19(1):33–38

Hürzeler MB, Quiñones CR, Kirsch A, Gloker C, Schüpbach P, Strub JR, Caffesse RG (1997) Maxillary sinus augmen-tation using different grafting materials and dental implants in monkeys. Part I. Evaluation of anorganic bovine-derived bone matrix. Clin Oral Implants Res 8(6):476–486

Hutchens LH Jr (1999) The use of a bovine bone mineral in periodontal osseous defects: case reports. Compend Contin Educ Dent 20:365–368

Ignatius AA, Schmidt C, Kaspar D, Claes LE (2001) In vitro biocompatibility of resorbable experimental glass ceramics for bone substitutes. J Biomed Mater Res 55:285–294

Ihoki M (1991) Experimental studies on induction of cartilage and bone by human dentin matrix. Nihon Koukuugeka Gakkaisi 12:1–14

Inoue T, Deporter DA, Melcher AH (1986a) Induction of car-tilage and bone by dentin demineralized in citric acid. J Periodontal Res 21(3):243–255

Inoue T, Deporter DA, Melcher AH (1986b) Induction of chon-drogenesis in muscle, skin, bone marrow, and periodontal ligament by demineralized dentin and bone matrix in vivo and in vitro. J Dent Res 65:12–22

Ito T, Shibukawa Y, Amano H, Kawai H, Yamada S (2002) Effect of calcium hydroxide paste on bone formation. J Dent Res 81:A–128, Abstract 0857

Jacobs JE, Rosenberg ES (1984) Management of an intrabony defect using osseous coagulum from a lingual torus. Compend Contin Educ Dent 5:57–63

Jang BJ, Byeon YE, Lim JH, Ryu HH, Kim WH, Koyama Y, Kikuchi M, Kang KS, Kweon OK (2008) Implantation of canine umbilical cord blood-derived mesenchymal stem cells mixed with beta-tricalcium phosphate enhances osteo-genesis in bone defect model dogs. J Vet Sci 9:387–393

Jarcho M (1981) Calcium phosphate ceramics as hard tissue prosthestics. Clin Orthop 157:259–278

Jarcho M, Kay JF, Gumaer KI, Doremus RH, Drobeck HP (1977) Tissue cellular and subcellular events at a bone-ceramics interface. J Bioeng 1:79–92

Jensen SS, Aaboe M, Pinholt EM, Hjørting-Hansen E, Melsen F, Ruyter IE (1996) Tissue reaction and material characteristics of four bone substitutes. Int J Oral Maxillofac Implants 11:55–66

Jensen SS, Yeo A, Dard M, Hunziker E, Schenk R, Buser D (2007) Evaluation of ael biphasic calcium phosphate in stan-dardized bone defects: a histologic and histomorphometric study in the mandibles of minipigs. Clin Oral Implants Res 18:752–760

Jónsson B, Mjöberg B (2009) Surgical treatment of depression fractures of the lateral tibial plateau using porous titanium granules. Ups J Med Sci 114:52–54

Juodzbalys G, Wang H-L (2007) Soft and hard tissue assessment of immediate implant placement: a case series. Clin Oral Implants Res 18:237–243

Kamitakahara M, Ohtsuki C, Miyazaki T (2008) Review paper: behavior of ceramic biomaterials derived from tricalcium phosphate in physiological condition. J Biomater Appl 23: 197–212

Karatzas S, Zavras A, Greenspan D, Amar S (1999) Histologic observations of periodontal wound healing after treatment with PerioGlas in nonhuman primates. Int J Periodontics Restorative Dent 19:489–499

Kasaj A, Willershausen B, Berakdar M, Tekyatan H, Sculean A (2006) Effect of an oily calcium hydroxide suspension on early wound healing after nonsurgical periodontal therapy. Clin Oral Investig 10:72–76

Kasaj A, Willershausen B, Jewszyk N, Schmidt M (2007) Effect of an oily calcium hydroxide suspension (Osteoinductal) on human periodontal fibroblasts. An in vitro study. Eur J Med Res 12:268–272

Kasaj A, Röhrig B, Zafiropoulos GG, Willershausen B (2008a) Clinical evaluation of nanocrystalline hydroxyapatite paste in the treatment of human periodontal bony defects–a random-ized controlled clinical trial: 6-month results. J Periodontol 79:394–400

Kasaj A, Willershausen B, Reichert C, Röhrig B, Smeets R, Schmidt M (2008b) Ability of nanocrystalline hydroxyapa-tite paste to promote human periodontal ligament cell prolif-eration. J Oral Sci 50:279–285

Kasperk C, Ewers R, Simons B, Kasperk R (1988) Algae-derived (phycogene) hydroxyapatite. Int J Oral Maxillofac Surg 17:319–324

Kassolis JD, Rosen PS, Reynolds MA (2000) Alveolar ridge and sinus augmentation utilizing platelet-rich plasma in combination with freeze-dried bone allograft: case series. J Periodontol 71:1654–1661

Kawai T, Urist MR (1989) A bovine tooth derived bone morpho-genetic protein. J Dent Res 68:1069–1074

Keles GC, Cetinkaya BO, Albayrak D, Koprulu H, Acikgoz G (2006) Comparison of platelet pellet and bioactive glass in peri-odontal regenerative therapy. Acta Odontol Scand 64:327–333


Kenney EB, Lekovic V, Han T, Carranza FA Jr, Dimitrijevic B (1985) The use of porous hydroxylapatite (HA) implant in periodontal defects. I. Clinical results after six months. J Periodontol 56:82–88

Kenney EB, Lekovic V, Sa Ferreira JC, Han T, Dimitrijevic B, Carranza FA Jr (1986) Bone formation within porous hydroxylapatite implants in human periodontal defects. J Periodontol 57:76–83

Kim C-K, Choi E-J, Cho K-S, Chai JK, Wikesjo UME (1996) Periodontal repair in intrabony defects treated with a cal-cium carbonate implant and guided tissue regeneration. J Periodontol 67:1301–1306

Kim CK, Chai JK, Cho KS, Moon IS, Choi SH, Sottosanti JS, Wikesjo UM (1998) Periodontal repair in intrabony defects treated with a calcium sulfate implant and calcium sulfate barrier. J Periodontol 69:1317–1324

Kim CS, Choi SH, Cho KS, Chai JK, Wikesjö UM, Kim CK (2005) Periodontal healing in one-wall intra-bony defects in dogs following implantation of autogenous bone or a coral-derived biomaterial. J Clin Periodontol 32:583–589

Kimble KM, Eber RM, Soehren S, Shyr Y, Wang HL (2004) Treatment of gingival recession using a collagen mem-brane with or without the use of demineralized freeze-dried bone allograft for space maintenance. J Periodontol 75:210–220

Kirsh ER, Garg AK (1994) Postextraction ridge maintenance using the endosseous ridgemaintenance implant (ERMI). Compendium 15:234, 236, 238 passim; quiz 244

Klongnoi B, Rupprecht S, Kessler P, Zimmermann R, Thorwarth M, Pongsiri S, Neukam FW, Wiltfang J, Schlegel KA (2006) Lack of beneficial effects of platelet-rich plasma on sinus-mentation using a fluorohydroxyapatite or autogenous bone: an explorative study. J Clin Periodontol 33:500–509

Knabe C, Driessens FC, Planell JA, Gildenhaar R, Berger G, Reif D, Fitzner R, Radlanski RJ, Gross U (2000) Evaluation of calcium phosphates and experimental calcium phosphate bone cements using osteogenic cultures. J Biomed Mater Res 52:498–508

Kohal RJ, Hürzeler MB, Schneider SR, Riede UN, Caffesse RG (1997) The effect of a calcium hydroxide paste on wound healing and osseointegration of dental implants. A pilot study in beagle dogs. Clin Oral Implants Res 8:375–385

Kolerman R, Tal H, Moses O (2008) Histomorphometric analy-sis of newly formed bone after maxillary sinus floor aug-mentation using ground cortical bone allograft and internal collagen membrane. J Periodontol 79:2104–2111

Kontonasaki E, Sivropoulou A, Papadopoulou L, Garefis P, Paraskevopoulos K, Koidis P (2007) Attachment and pro-liferation of human periodontal ligament fibroblasts on bio-active glass modified ceramics. J Oral Rehabil 34:57–67

Koo KT, Polimeni G, Qahash M, Kim CK, Wikesjö UM (2005) Periodontal repair in dogs: guided tissue regeneration enhances bone formation in sites implanted with a coral-derived calcium carbonate biomaterial. J Clin Periodontol 32:104–110

Kothiwale SV, Anuroopa P, Gajiwala AL (2009) A clinical and radiological evaluation of DFDBA with amniotic membrane versus bovine derived xenograft with amniotic membrane in human periodontal grade II furcation defects. Cell Tissue Bank 10:317–326

Kotschy P, Laky M (2006) Reconstruction of supracrestal alve-olar bone lost as a result of severe chronic periodontitis. Five-year outcome: case report. Int J Periodontics Restorative Dent 26:425–431

Kuo TC, Lee BS, Kang SH, Lin FH, Lin CP (2007) Cytotoxicity of DP-bioglass paste used for treatment of dentin hypersen-sitivity. J Endod 33:451–454

Kuru B, Yilmaz S, Argin K, Noyan U (2006) Enamel matrix derivative alone or in combination with a bioactive glass in wide intrabony defects. Clin Oral Investig 10:227–234

Kwon HR, Wikesjö UM, Park JC, Kim YT, Bastone P, Pippig SD, Kim CK (2010) Growth/differentiation factor-5 sig-nificantly enhances periodontal wound healing/regeneration compared with platelet-derived growth factor-BB in dogs. J Clin Periodontol 37:739–746

Lamb JW 3rd, Greenwell H, Drisko C, Henderson RD, Scheetz JP, Rebitski G (2001) A comparison of porous and non-porous teflon membranes plus demineralized freeze-dried bone allograft in the treatment of class II buccal/lingual furcation defects: a clinical reentry study. J Periodontol 72:1580–1587

Lang NP, Tonetti MS, Suvan JE, Bernard JP, Botticelli D, Fourmousis I, Hallund M, Jung R, Laurell L, Salvi GE, Shafer D, Weber H-P (2007) Immediate implant placement with transmucosal healing in areas of aesthetic priority: a multicentre randomized-controlled clinical trial I. Surgical outcomes. Clin Oral Implants Res 18:188–196

Larsson S (2010) Calcium phosphates: what is the evidence? J Orthop Trauma 24(Suppl 1):S41–S45

Laschke MW, Witt K, Pohlemann T, Menger MD (2007) Injectable nanocrystalline hydroxyapatite paste for bone sub-stitution: In vivo analysis of biocompatibility and vascular-ization. J Biomed Mater Res B Appl Biomater 82:494–505

Laurell L, Gottlow J, Zybutz M, Persson R (1998) Treatment of intrabony defects by different surgical procedures. A litera-ture review. J Periodontol 69:303–313

Lee BS, Tsai HY, Tsai YL, Lan WH, Lin CP (2005) In vitro study of DP-bioglass paste for treatment of dentin hypersen-sitivity. Dent Mater J 24:562–569

Lee BS, Kang SH, Wang YL, Lin FH, Lin CP (2007) In vitro study of dentinal tubule occlusion with sol-gel DP-bioglass for treatment of dentin hypersensitivity. Dent Mater J 26:52–61

Lee CY, Rohrer MD, Prasad HS, Stover JD, Suzuki JB (2009) Sinus grafting with a natural fluorohydroxyapatite for imme-diate load: a study with histologic analysis and histomor-phometry. J Oral Implantol 35:164–175

Lee SB, Jung UW, Choi Y, Jamiyandorj O, Kim CS, Lee YK, Chai JK, Choi SH (2010) Investigation of bone forma-tion using calcium phosphate glass cement in beagle dogs. J Periodontal Implant Sci 40:125–131

Leknes KN, Andersen KM, Bøe OE, Skavland RJ, Albandar JM (2009) Enamel matrix derivative versus bioactive ceramic filler in the treatment of intrabony defects: 12-month results. J Periodontol 80:219–227

Lekovic V, Camargo PM, Weinlaender M, Nedic M, Aleksic Z, Kenney EB (2000) A comparison between enamel matrix proteins used alone or in combination with bovine porous bone mineral in the treatment of intrabony periodontal defects in humans. J Periodontol 71:1110–1116

Lekovic V, Camargo PM, Weinlaender M, Vasilic N, Djordjevic M, Kenney EB (2001) The use of bovine porous bone

135References

mineral in combination with enamel matrix proteins or with an autologous fibrinogen/fibronectin system in the treatment of intrabony periodontal defects in humans. J Periodontol 72:1157–1163

Leung G, Jin L (2003) A combined approach of enamel matrix derivative gel and autogenous bone grafts in treatment of intrabony periodontal defects. A case report. Prim Dent Care 10(2):41–43

Levin MP, Getter L, Adrian J, Cutright DE (1974) Healing of periodontal defects with ceramic implants. J Clin Periodontol 1:197–205

Li H, Pujic Z, Xiao Y, Bartold PM (2000) Identification of bone morphogenetic proteins 2 and 4 in commercial demineral-ized freeze-dried bone allograft preparations: pilot study. Clin Implant Dent Relat Res 2:110–117

Lim HC, Sohn JY, Park JC, Um YJ, Jung UW, Kim CS, Lee YK, Choi SH (2010) Osteoconductive effects of calcium phosphate glass cement grafts in rabbit calvarial defects. J Biomed Mater Res B Appl Biomater 95:47–52

Lin KY, Bartlett SP, Yaremchuk MJ, Fallon M, Grossman RF, Whitaker LA (1990) The effect of rigid fixation on the sur-vival of onlay bone grafts: an experimental study. Plast Reconstr Surg 86:449–456

Liñares A, Cortellini P, Lang NP, Suvan J, Tonetti MS, European Research Group on Periodontology (ErgoPerio) (2006) Guided tissue regeneration/deproteinized bovine bone mineral or papilla preservation flaps alone for treatment of intrabony defects. II: radiographic predictors and outcomes. J Clin Periodontol 33:351–358

Lindfors LT, Tervonen EA, Sándor GK, Ylikontiola LP (2010) Guided bone regeneration using a titanium-reinforced ePTFE membrane and particulate autogenous bone: the effect of smoking and membrane exposure. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 109:825–830

Lohmann CH, Andreacchio D, Köster G, Carnes DL Jr, Cochran DL, Dean DD, Boyan BD, Schwartz Z (2001) Tissue response and osteoinduction of human bone grafts in vivo. Arch Orthop Trauma Surg 121:583–590

Louise F, Fourel J, Roig R (1985) Bioceramics in periodontal bone surgery. Clinical trial of Synthograft. J Parodontol 4:277–285

Lovelace TB, Mellonig JT, Meffert RM, Jones AA, Nummikoski PV, Cochran DL (1998) Clinical evaluation of bioactive glass in the treatment of periodontal osseous defects in humans. J Periodontol 69:1027–1035

Low SB, King CJ, Krieger J (1997) An evaluation of bioactive ceramic in the treatment of periodontal osseous defects. Int J Periodontics Restorative Dent 17:358–367

Lu Z, Zreiqat H (2010a) Beta-tricalcium phosphate exerts osteo-conductivity through alpha2beta1 integrin and down-stream MAPK/ERK signaling pathway. Biochem Biophys Res Commun 394:323–329

Lu Z, Zreiqat H (2010b) The osteoconductivity of biomaterials is regulated by bone morphogenetic protein 2 autocrine loop involving a2b1 integrin and mitogen-activated protein kinase/extracellular related kinase signaling pathways. Tissue Eng A 16:3075–3084

Lu JX, Gallur A, Flautre B, Anselme K, Descamps M, Thierry B et al (1998) Comparative study of tissue reactions to cal-cium phosphate ceramics among cancellous, cortical, and

medullar bone sites in rabbits. J Biomed Mater Res 42: 357–367

Mabry TW, Yukna RA, Sepe WW (1985) Freeze-dried bone allografts combined with tetracycline in the treatment of juvenile periodontitis. J Periodontol 56:74–81

Machado ME, Souza AS, Araújo VC (2006) Histological evalu-ation of the osteoinduction capability of human dentine. Int Endod J 39:855–859

Magistri A, Botticelli L, Romitelli AM, De Luca P, Evangelisti N, Guadagno I (2006) Trattamento delle grandi cavità cis-tiche con biomateriali [Treatment of large cystic cavities with biomaterial]. Chir Orale 2:16–19

Maragos P, Bissada NF, Wang R, Cole BP (2002) Comparison of three methods using calcium sulfate as a graft/barrier mate-rial for the treatment of Class II mandibular molar furcation defects. Int J Periodontics Restorative Dent 22:493–501

Markopoulou CE, Vrotsos IA, Vavouraki HN, Dereka XE, Mantzavinos ZS (2003) Human periodontal ligament cell res-ponses to recombinant human bone morphogenetic protein-2 with and without bone allografts. J Periodontol 74:982–989

Markou N, Pepelassi E, Vavouraki H, Stamatakis HC, Nikolopoulos G, Vrotsos I, Tsiklakis K (2009) Treatment of perio dontal endosseous defects with platelet-rich plasma alone or in combination with demineralized freeze-dried bone allograft: a comparative clinical trial. J Periodontol 80: 1911–1919

Markou N, Pepelassi E, Kotsovilis S, Vrotsos I, Vavouraki H, Stamatakis HC (2010) The use of platelet-rich plasma com-bined with demineralized freeze-dried bone allograft in the treatment of periodontal endosseous defects: a report of two clinical cases. J Am Dent Assoc 141:967–978

Marx RE (1994) Clinical application of bone biology to man-dibular and maxillary reconstruction. Clin Plast Surg 21:377–392

Masters L, Mellonig J, Brunsvold M, Numikowski P (1996) A clinical evaluation of demineralized freeze dried bone allograft in combination with tetracycline in the treatment of periodontal osseous defects. J Periodontol 67:770–781

McGuire MK, Kao RT, Nevins M, Lynch SE (2006) rhPDGF-BB promotes healing of periodontal defects: 24-month clini-cal and radiographic observations. Int J Periodontics Restorative Dent 26:223–231

McGuire MK, Scheyer ET, Schupbach P (2009a) Growth factor-mediated treatment of recession defects: a randomized con-trolled trial and histologic and microcomputed tomography examination. J Periodontol 80:550–564

McGuire MK, Scheyer T, Nevins M, Schupbach P (2009b) Eva lu ation of human recession defects treated with coro-nally advanced flaps and either purified recombinant human platelet-derived growth factor-BB with beta tricalcium phos-phate or connective tissue: a histologic and microcomputed tomographic examination. Int J Periodontics Restorative Dent 29:7–21

Meadows CL, Gher ME, Quintero G, Lafferty TA (1993) A comparison of polylactic acid granules and decalcified freeze-dried bone allograft in human periodontal osseous defects. J Periodontol 64:103–109

Mellonig JT (1984) Calcified freeze-dried bone allograft as an implant material in human periodontal defects. Int J Periodontics Restorative Dent 4:40–55


Mellonig JT (1992) Autogenous and allogeneic bone grafts in periodontal therapy. Crit Rev Oral Biol Med 3:333–352

Mellonig J (2000) Human histologic evaluation of a bovine-derived xenograft in the treatment of periodontal osseous defects. Int J Periodontics Restorative Dent 20:19–29

Mellonig JT, Prewett AB, Moyer MP (1992) HIV inactivation in a bone allograft. J Periodontol 63:979–983

Mellonig JT, Valderrama Mdel P, Cochran DL (2009) Histological and clinical evaluation of recombinant human platelet-derived growth factor combined with beta tricalcium phosphate for the treatment of human Class III furcation defects. Int J Periodontics Restorative Dent 29:169–177

Mellonig JT, Valderrama P, Cochran DL (2010) Clinical and histologic evaluation of calcium-phosphate bone cement in interproximal osseous defects in humans: a report in four patients. Int J Periodontics Restorative Dent 30: 121–127

Mengel R, Soffner M, Flores-de-Jacoby L (2003) Bioabsorbable membrane and bioactive glass in the treatment of intrabony defects in patients with generalized aggressive periodon-titis: results of a 12-month clinical and radiological study. J Periodontol 74:899–908

Mengel R, Schreiber D, Flores-de-Jacoby L (2006) Bioabsorbable membrane and bioactive glass in the treatment of intrabony defects in patients with generalized aggressive periodon-titis: results of a 5-year clinical and radiological study. J Periodontol 77:1781–1787

Meraw SJ, Reeve CM, Lohse CM, Sioussat TM (2000) Treatment of peri-implant defects with combination growth factor cement. J Periodontol 71:8–13

Merkx MAW, Maltha JC, Stoelinga PJW (2003) Assessment of the value of anorganic bone additives in sinus floormentation: a review of clinical reports. Int J Oral Maxillofac Surg 32:1–6

Metsger DS, Driskell TD, Paulsrud JR (1982) Tricalcium phos-phate ceramic–a resorbable bone implant: review and cur-rent status. J Am Dent Assoc 105:1035–1038

Misch CE (1999) Contemporary implant dentistry, 2nd edn. Mosby, Pittsburgh, pp 452–476

Misch CE, Dietsh F (1993) Bone-grafting materials in implant dentistry. Implant Dent 2:158–167

Moghadam HG, Sandor GK, Holmes HH, Clokie CM (2004) Histomorphometric evaluation of bone regeneration using allogeneic and alloplastic bone substitutes. J Oral Maxillofac Surg 62:202–213

Mora F, Ouhayoun JP (1995) Clinical evaluation of natural coral and porous hydroxyapatite implants in periodontal bone lesions: results of a 1-year follow-up. J Clin Periodontol 22:877–884

Mott DA, Mailhot J, Cuenin MF, Sharawy M, Borke J (2002) Enhancement of osteoblast proliferation in vitro by selec-tive enrichment of demineralized freeze-dried bone allograft with specific growth factors. J Oral Implantol 28:57–66

Movin S, Borring-Møller G (1982) Regeneration of infrabony periodontal defects in humans after implantation of allogenic demineralized dentin. J Clin Periodontol 9(2):141–147

Munukka E, Leppäranta O, Korkeamäki M, Vaahtio M, Peltola T, Zhang D, Hupa L, Ylänen H, Salonen JI, Viljanen MK, Eerola E (2008) Bactericidal effects of bioactive glasses on clinically important aerobic bacteria. J Mater Sci Mater Med 19:27–32

Muramatsu T, Hamano H, Fukumashi K, Shiigai T, Fujiseki M, Katayanagi T, Osada K, Inoue T, Shimono M (1993) An experimental study of chondrogenesis and osteogenesis in rat submandibular gland induced by implantation of demin-eralized dentin. Bull Tokyo Dent Coll 34:15–22

Murphy KG, Gunsolley JC (2003) Guided tissue regeneration for the treatment of periodontal intrabony and furcation defects. A systematic review. Ann Periodontol 8(1) :266–302

Nakanishi S, Ota M, Shibukawa Y, Yamada S (2009) C-Graft in regeneration of periodontal tissue in intrabony periodontal defect in dog. J Biomater Appl 24:89–104

Nandi SK, Roy S, Mukherjee P, Kundu B, De DK, Basu D (2010) Orthopaedic applications of bone graft and graft sub-stitutes: a review. Indian J Med Res 132:15–30

Nannmark U, Azarmehr I (2010) Short communication: colla-genated cortico-cancellous porcine bone grafts. A study in rabbit maxillary defects. Clin Implant Dent Relat Res 12:161–163

Nannmark U, Sennerby L (2008) The bone tissue responses to prehydrated and collagenated corticocancellous porcine bone grafts: a study in rabbit maxillary defects. Clin Implant Dent Relat Res 10:264–270

Nasr HF, Aichelmann-Reidy ME, Yukna RA (1999) Bone and bone substitutes. Periodontol 2000 19:74–86

Neamat A, Gawish A, Gamal-Eldeen AM (2009) beta-Trical-cium phosphate promotes cell proliferation, osteogenesis and bone regeneration in intrabony defects in dogs. Arch Oral Biol 54:1083–1090

Needleman IG, Giedrys-Leeper E, Tucker RJ, Worthington HV (2001) Guided tissue regeneration for periodontal infra-bony defects. Cochrane Database Syst Rev 2:CD001724

Nery EB, Lynch KL (1978) Preliminary clinical studies of bio-ceramic in periodontal osseous defects. J Periodontol 49:523–527

Nery EB, LeGeros RZ, Lynch KL, Lee K (1992) Tissue response to biphasic calcium phosphate ceramic with different ratios of HA/beta TCP in periodontal osseous defects. J Periodontol 63:729–735

Nevins ML, Camelo M, Nevins M, Nevins M, King CJ, Oringer RJ, Schenk RK, Fiorellini JP (2000) Human histologic eval-uation of bioactive ceramic in the treatment of periodontal osseous defects. Int J Periodontics Restorative Dent 20:458–467

Nevins M, Camelo M, Nevins ML, Schenk RK, Lynch SE (2003a) Periodontal regeneration in humans using recombi-nant human platelet-derived growth factor-BB (rhPDGF-BB) and allogenic bone. J Periodontol 74(9):1282–1292

Nevins ML, Camelo M, Lynch SE, Schenk RK, Nevins M (2003b) Evaluation of periodontal regeneration following grafting intrabony defects with bio-oss collagen: a human histologic report. Int J Periodontics Restorative Dent 23:9–17

Nevins M, Giannobile WV, McGuire MK, Kao RT, Mellonig JT, Hinrichs JE, McAllister BS, Murphy KS, McClain PK, Nevins ML, Paquette DW, Han TJ, Reddy MS, Lavin PT, Genco RJ, Lynch SE (2005a) Platelet-derived growth fac-tor stimulates bone fill and rate of attachment level gain: results of a large multicenter randomized controlled trial. J Periodontol 76:2205–2215

Nevins ML, Camelo M, Rebaudi A, Lynch SE, Nevins M (2005b) Three-dimensional micro-computed tomographic

137References

evaluation of periodontal regeneration: a human report of intrabony defects treated with Bio-Oss collagen. Int J Periodontics Restorative Dent 25:365–373

Nevins M, Hanratty J, Lynch SE (2007) Clinical results using recombinant human platelet-derived growth factor and min-eralized freeze-dried bone allograft in periodontal defects. Int J Periodontics Restorative Dent 27:421–427

Ning Y, Wei T, Defu C, Yonggang X, Da H, Dafu C, Lei S, Zhizhong G (2009) The research of degradability of ael bio-degradable coralline hydroxyapatite after implanted into rabbit. J Biomed Mater Res A 88:741–746

Noetzel J, Ozer K, Reisshauer BH, Anil A, Rössler R, Neumann K, Kielbassa AM (2006) Tissue responses to an experimen-tal calcium phosphate cement and mineral trioxide aggre-gate as materials for furcation perforation repair: a histological study in dogs. Clin Oral Investig 10:77–83

Nygaard-Østby P, Bakke V, Nesdal O, Nilssen HK, Susin C, Wikesjö UM (2008) Periodontal healing following reconstructive surgery: effect of guided tissue regenera-tion using a bioresorbable barrier device when combined with autogenous bone grafting. A randomized controlled clinical trial. J Clin Periodontol 35:37–43

Nygaard-Østby P, Bakke V, Nesdal O, Susin C, Wikesjö UM (2010) Periodontal healing following reconstructive surgery: effect of guided tissue regeneration using a bioresorbable barrier device when combined with autogenous bone graft-ing. A randomized-controlled trial 10-year follow-up. J Clin Periodontol 37:366–373

Ogawa T, Yamada T, Miura F, Miyazaki S, Machida H, Akimoto Y, Hagiwara K, Kawanishi F, Shirakawa M, Okamoto H (1985) [Clinical evaluation of bone grafts in periodontal surgery. 1. Use of autogenous bone grafts in 2- and 3-walled interproxi-mal bone defects]. Hiroshima Daigaku Shigaku Zasshi 17(1): 214–220

Oguntebi B, Clark A, Wilson J (1993) Pulp capping with Bioglass and autologous demineralized dentin in miniature swine. J Dent Res 72:484–489

Ohgaki M, Kizuki T, Katsura M, Yamashita K (2001) Manipulation of selective cell adhesion and growth by surface charges of electrically polarized hydroxyapatite. J Biomed Mater Res 57:366–373

Okuda K, Tai H, Tanabe K, Suzuki H, Sato T, Kawase T, Saito Y, Wolff LF, Yoshie H (2005) Platelet-rich plasma combined with a porous hydroxyapatite graft for the treatment of intra-bony periodontal defects in humans: a comparative con-trolled clinical study. J Periodontol 76:890–898

Ong MM, Eber RM, Korsnes MI, MacNeil RL, Glickman GN, Shyr Y, Wang HL (1998) Evaluation of a bioactive glass allo-plast in treating periodontal intrabony defects. J Periodontol 69:1346–1354

Oonishi H, Kushitani S, Yasukawa E, Iwaki H, Hench LL, Wilson J, Tsuji E, Sugihara T (1997) Particulate bioglass compared with hydroxyapatite as a bone graft substitute. Clin Orthop 334:316–325

Oreamuno S, Lekovic V, Kenney EB, Carranza FA Jr, Takei HH, Prokic B (1990) Comparative clinical study of porous hydroxyapatite and decalcified freeze-dried bone in human periodontal defects. J Periodontol 61:399–404

Orsini M, Orsini G, Benlloch D, Aranda JJ, Lazaro P, Sanz M, De Luca M, Piattelli A (2001) Comparison of calcium sulfate and autogenous bone graft to bioabsorbable membranes plus

autogenous bone graft in the treatment of intrabony peri-odontal defects: a split-mouth study. J Periodontol 72: 296–302

Orsini G, Traini T, Scarano A, Degidi M, Perrotti V, Piccirilli M, Piattelli A (2005) Maxillary sinusmentation with Bio-Oss particles: a light, scanning, and transmission electron micros-copy study in man. J Biomed Mater Res B Appl Biomater 74:448–457

Orsini M, Orsini G, Benlloch D, Aranda JJ, Sanz M (2008) Long-term clinical results on the use of bone-replacement grafts in the treatment of intrabony periodontal defects. Comparison of the use of autogenous bone graft plus cal-cium sulfate to autogenous bone graft covered with a bioab-sorbable membrane. J Periodontol 79:1630–1637

Otsuka M, Matsuda Y, Suwa Y, Fox JL, Higuchi WI (1994) A novel skeletal drug-delivery system using self-setting calcium phosphate cement. 3. Physicochemical properties and drug-release rate of bovine insulin and bovine albumin. J Pharm Sci 83:255–258

Pagliani L, Andersson P, Lanza M, Nappo A, Verrocchi D, Volpe S, Sennerby L (2010) A collagenated porcine bone substitute for augmentation at Neoss implant sites: a prospective 1-year multicenter case series study with histology. Clin Implant Dent Relat Res. doi: 10.1111/j.1708-8208.2010.00314.x [Epub ahead of print]

Pagliani L, Volpe S. Localized bone regeneration with porcine bone graft: clinical and histological evidences. Retrieved at http://www.orimeda.lt/out/oxbaseshop/html/0/images/wysi-wigpro/OsteoBiol/ Abstracts_2010.03.24.pdf

Palmieri A, Pezzetti F, Spinelli G, Arlotti M, Avantaggiato A, Scarano A, Scapoli L, Zollino I, Carinci F (2008) PerioGlas regulates osteoblast RNA interfering. J Prosthodont 17(7):522–526

Palmieri A, Pezzetti F, Brunelli G, Martinelli M, Lo Muzio L, Scarano A, Scapoli L, Arlotti M, Guerzoni L, Carinci F (2010) Anorganic bovine bone (Bio-Oss) regulates miRNA of osteoblast-like cells. Int J Periodontics Restorative Dent 30:83–87

Palti A, Hoch T (2002) A concept for the treatment of various dental bone defects. Implant Dent 11(1):73–78

Paolantonio M (2002) Combined periodontal regenerative tech-nique in human intrabony defects by collagen membranes and anorganic bovine bone. A controlled clinical study. J Periodontol 73:158–166

Paolantonio M, Scarano A, Di Placido G, Tumini V, D’Archivio D, Piattelli A (2001) Periodontal healing in humans using anorganic bovine bone and bovine peritoneum-derived col-lagen membrane: a clinical and histologic case report. Int J Periodontics Restorative Dent 21:505–515

Paolantonio M, Perinetti G, Dolci M, Perfetti G, Tetè S, Sammartino G, Femminella B, Graziani F (2008) Surgical treatment of periodontal intrabony defects with calcium sul-fate implant and barrier versus collagen barrier or open flap debridement alone: a 12-month randomized controlled clini-cal trial. J Periodontol 79:1886–1893

Papadopoulos CE, Dereka XE, Vavouraki EN, Vrotsos IA (2003) In vitro evaluation of the mitogenic effect of platelet-derived growth factor-BB on human periodontal ligament cells cul-tured with various bone allografts. J Periodontol 74:451–457

Park JS, Suh JJ, Choi SH, Moon IS, Cho KS, Kim CK, Chai JK (2001) Effects of pretreatment clinical parameters


on bioactive glass implantation in intrabony periodontal defects. J Periodontol 72:730–740

Parodi R, Santarelli G, Carusi G (1996) Application of slow-resorbing collagen membrane to periodontal and peri-implant guided tissue regeneration. Int J Periodontics Restorative Dent 16:174–185

Peters CL, Hines JL, Bachus KN, Craig MA, Bloebaum RD (2006) Biological effects of calcium sulfate as a bone graft substitute in ovine metaphyseal defects. J Biomed Mater Res A 76(3):456–462

Piattelli A, Scarano A, Corigliano M, Piattelli M (1996a) Comparison of bone regeneration with the use of mineralized and demineralized freeze-dried bone allografts: a histological and histochemical study in man. Biomaterials 17:1127–1131

Piattelli A, Scarano A, Mangano C (1996b) Clinical and histo-logic aspects of biphasic calcium phosphate ceramic (BCP) used in connection with implant placement. Biomaterials 17:1767–1770

Piattelli A, Podda G, Scarano A (1997) Clinical and histological results in alveolar ridge enlargement using coralline calcium carbonate. Biomaterials 18:623–627

Piattelli M, Favero GA, Scarano A, Orsini G, Piattelli A (1999) Bone reactions to anorganic bovine bone (Bio-Oss) used in sinusmentation procedures: a histologic long-term report of 20 cases in humans. Int J Oral Maxillofac Implants 14:835–840

Piemontese M, Aspriello SD, Rubini C, Ferrante L, Procaccini M (2008) Treatment of periodontal intrabony defects with demineralized freeze-dried bone allograft in combina-tion with platelet-rich plasma: a comparative clinical trial. J Periodontol 79:802–810

Pietruska MD (2001) A comparative study on the use of Bio-Oss® and enamel matrix derivative (Emdogain®) in the treatment of periodontal bone defects. Eur J Oral Sci 109:178–181

Polimeni G, Koo KT, Qahash M, Xiropaidis AV, Albandar JM, Wikesjö UM (2004) Prognostic factors for alveolar regen-eration: effect of a space-providing biomaterial on guided tissue regeneration. J Clin Periodontol 31:725–729

Polimeni G, Xiropaidis AV, Wikesjo UM (2006) Biology and principles of periodontal wound healing/regeneration. Periodontol 2000 41:30–47

Pollick S, Shors EC, Holmes RE, Kraut RA (1995) Bone forma-tion and implant degradation of coralline porous ceramics placed in bone and ectopic sites. J Oral Maxillofac Surg 53:915–922

Prakash S, Sunitha J, Abid S (2010) Evaluation of HTR polymer (Bioplant HTR) as a bone graft material in the treatment of interproximal vertical bony defects: a clinical and radiologi-cal study. Indian J Dent Res 21(2):179–184

Precheur HV (2007) Bone graft materials. Dent Clin North Am 51(3):729–746

Price N, Bendall SP, Frondoza C, Jinnah RH, Hungerford DS (1997) Human osteoblast-like cells (MG63) proliferate on bioactive glass surface. J Biomed Mater Res 37:394–400

Pripatnanont P, Nuntanaranont T, Vongvatcharanon S (2009) Proportion of deproteinized bovine bone and autogenous bone affects bone formation in the treatment of calvarial defects in rabbits. Int J Oral Maxillofac Surg 38:356–362

Quattlebaum JB, Mellonig JT, Hensel NF (1988) Antigenicity of freeze-dried cortical bone allograft in human periodontal osseous defects. J Periodontol 59:394–397

Rafter M, Baker M, Alves M, Daniel J, Remeikis N (2002) Evaluation of healing with use of an internal matrix to repair furcation perforations. Int Endod J 35:775–783

Rajesh JB, Nandakumar K, Varma HK, Komath M (2009) Calcium phosphate cement as a “barrier-graft” for the treat-ment of human periodontal intraosseous defects. Indian J Dent Res 20:471–479

Reddi AH, Huggins CB (1973) Influence of geometry of trans-planted tooth and bone on transformation of fibroblasts. Proc Soc Exp Biol Med 143:634–637

Reddy KP, Nayak DG, Uppoor AS (2006) A clinical evaluation of anorganic bovine bone graft plus 10% collagen with or without a barrier in the treatment of class II furcation defects. J Contemp Dent Pract 7:60–70

Renooji W, Hoogendoorn A, Visser WJ, Lentferkink RHF, Schimitz MGJ, Ieperen HV et al (1985) Bioresorption of ceramic strontium-85-labelde calcium phosphate implants in dog femora. Clin Orthop 197:272–285

Renvert S, Garrett S, Nilvéus R, Chamberlain AD, Egelberg J (1985a) Healing after treatment of periodontal intraosseous defects. VI. Factors influencing the healing response. J Clin Periodontol 12:707–715

Renvert S, Garrett S, Shallhorn RG, Egelberg J (1985b) Healing after treatment of periodontal intraosseous defects. III. Effect of osseous grafting and citric acid conditioning. J Clin Periodontol 12:441–455

Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, Gunsolley JC (2003) The efficacy of bone replacement grafts in the treatment of periodontal osseous defects. Ann Periodontol 8:227–265

Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL (2010) Regeneration of periodontal tissue: bone replacement grafts. Dent Clin North Am 54:55–71

Ricci JL, Blumenthal NC, Spivak JM, Alexander H (1992) Evaluation of a lowtemperature calcium phosphate particulate implant material: physical-chemical properties and in vivo bone response. Int J Oral Maxillofac Surg 50:969–978

Richardson CR, Mellonig JT, Brunsvold MA, McDonnell HT, Cochran DL (1999) Clinical evaluation of Bio-Oss: a bovine-derived xenograft for the treatment of periodontal osseous defects in humans. J Clin Periodontol 26:421–428

Ridgway HK, Mellonig JT, Cochran DL (2008) Human histo-logic and clinical evaluation of recombinant human plate-let-derived growth factor and beta-tricalcium phosphate for the treatment of periodontal intraosseous defects. Int J Periodontics Restorative Dent 28:171–179

Ripamonti U, Crooks J, Khoali L, Roden L (2009) The induc-tion of bone formation by coral-derived calcium carbonate/hydroxyapatite constructs. Biomaterials 30:1428–1439

Ritchie HH, Ritchie DG, Wang LH (1998) Sixades of dentinogen-esis research. Historical and prospective views on phospho-phoryn and dentin sialoprotein. Eur J Oral Sci 106:211–220

Rivault AF, Toto PD, Levy S, Gargiulo AW (1971) Autogenous bone grafts: osseous coagulum and osseous retrograde pro-cedures in primates. J Periodontol 42:787–796

Robinson E (1969) Osseous coagulum for bone induction. J Periodontol 40:503–510

Rosen PS, Reynolds MA (1999) Polymer-assisted regenerative therapy: case reports of 22 consecutively treated periodontal defects with ael combined surgical approach. J Periodontol 70:554–561

139References

Rosen PS, Reynolds MA (2001) Guided bone regeneration for dehiscence and fenestration defects on implants using an absorbable polymer barrier. J Periodontol 72:250–256

Rosen PS, Reynolds MA (2002) A retrospective case series comparing the use of demineralized freeze-dried bone allograft and freeze-dried bone allograft combined with enamel matrix derivative for the treatment of advanced osseous lesions. J Periodontol 73:942–949

Rosen PS, Reynolds MA, Bowers GM (2000) The treatment of intrabony defects with bone grafts. Periodontol 2000 22:88–103

Rosenberg E, Rose LF (1998) Biologic and clinical consider-ations for autografts and allografts in periodontal regenera-tion therapy. Dent Clin North Am 42:467–490

Rosenberg ES, Fox GK, Cohen C (2000) Bioactive glass gran-ules for regeneration of human periodontal defects. J Esthet Dent 12:248–257

Rummelhart JM, Mellonig JT, Gray JL, Towle HJ (1989) A com-parison of freeze-dried bone allograft and demineralized freeze-dried bone allograft in human periodontal osseous defects. J Periodontol 60:655–663

Sabetrasekh R, Tiainen H, Lyngstadaas SP, Reseland J, Haugen H (2011) A novel ultra-porous titanium dioxide ceramic with excellent biocompatibility. J Biomater Appl 25(6):559–580

Saffar JL, Colombier ML, Detienville R (1990) Bone forma-tion in tricalcium phosphate-filled periodontal intrabony lesions. Histological observations in humans. J Periodontol 61:209–216

Sakata J, Abe H, Ohazama A, Okubo K, Nagashima C, Suzuki M, Hasegawa K (2006) Effects of combined treatment with porous bovine inorganic bone grafts and bilayer porcine ollagen membrane on refractory one-wall intrabony defects. Int J Periodontics Restorative Dent 26:161–169

Sanders JJ, Sepe WW, Bowers GM, Koch RW, Williams JE, Lekas JS, Mellonig JT, Pelleu GB Jr, Gambill V (1983) Clinical evaluation of freeze-dried bone allografts in peri-odontal osseous defects. Part III. Composite freeze-dried bone allografts with and without autogenous bone grafts. J Periodontol 54:1–8

Sapkos SW (1986) The use of periograft in periodontal defects. Histologic findings. J Periodontol 57:7–13

Sarment DP, Cooke JW, Miller SE, Jin Q, McGuire MK, Kao RT, McClain PK, McAllister BS, Lynch SE, Giannobile WV (2006) Effect of rhPDGF-BB on bone turnover during peri-odontal repair. J Clin Periodontol 33:135–140

Sato I, Akizuki T, Oda S, Tsuchioka H, Hayashi C, Takasaki AA, Mizutani K, Kawakatsu N, Kinoshita A, Ishikawa I, Izumi Y (2009) Histological evaluation of alveolar ridge-mentation using injectable calcium phosphate bone cement in dogs. J Oral Rehabil 36:762–769

Scabbia A, Trombelli L (2004) A comparative study on the use of a HA/collagen/chondroitin sulphate biomaterial (Biostites) and a bovine-derived HA xenograft (Bio-Osss) in the treatment of deep intra-osseous defects. J Clin Periodontol 31:348–355

Schallhorn RG, Hiatt WH (1972) Human allografts of iliac can-cellous bone androw in periodontal osseous defects. II. Clinical observations. J Periodontol 43:67–81

Schepers E, de Clercq M, Ducheyne P, Kempeneers R (1991) Bioactive glass particulate material as a filler for bone lesions. J Oral Rehabil 18:439–452

Schepers EJ, Ducheyne P, Barbier L, Schepers S (1993) Bioactive glass particles of narrow size range: a new material for the repair of bone defects. Implant Dent 2:151–156

Schepers E, Barbier L, Ducheyne P (1998) Implant placement enhanced by bioactive glass particles of narrow size range. Int J Oral Maxillofac Implants 13:655–665

Scheyer ET, Velasquez-Plata D, Brunsvold MA, Lasho DJ, Mellonig JT (2002) A clinical comparison of a bovine-derived xenograft used alone and in combination with enamel matrix derivative for the treatment of periodontal osseous defects in humans. J Periodontol 73:423–432

Schlegel AK, Donath K (1998) Bio-Oss®: a resorbable bone substitute? J Long Term Eff Med Implants 8:201–209

Schopper C, Moser D, Sabbas A, Lagogiannis G, Spassova E, Konig F, Donath K, Ewers R (2003) The fluorohydroxyapa-tite (FHA) FRIOS Algipore is a suitable biomaterial for the reconstruction of severely atrophic human maxillae. Clin Oral Implants Res 14:743–749

Schou S, Holmstrup P, Jørgensen T, Skovgaard LT, Stoltze K, Hjørting-Hansen E, Wenzel A (2003) Anorganic porous bovine-derived bone mineral (Bio-Oss) and ePTFE mem-brane in the treatment of peri-implantitis in cynomolgus monkeys. Clin Oral Implants Res 14:535–547

Schrad SC, Tussing GJ (1986) Human allografts of iliac bone androw in periodontal osseous defects. J Periodontol 57: 205–210

Schulz A, Hilgers RD, Niedermeier W (2000) The effect of splinting of teeth in combination with reconstructive periodontal surgery in humans. Clin Oral Investig 4(2): 98–105

Schwartz Z, Mellonig JT, Carnes DL Jr, de la Fontaine J, Cochran DL, Dean DD, Boyan BD (1996) Ability of com-mercial demineralized freeze-dried bone allograft to induce new bone formation. J Periodontol 67:918–926

Schwartz Z, Somers A, Mellonig JT, Carnes DL Jr, Dean DD, Cochran DL, Boyan BD (1998a) Ability of commercial demineralized freeze-dried bone allograft to induce new bone formation is dependent on donor age but not gender. J Periodontol 69:470–478

Schwartz Z, Somers A, Mellonig JT, Carnes DL Jr, Wozney JM, Dean DD, Cochran DL, Boyan BD (1998b) Addition of human recombinant bone morphogenetic protein-2 to inac-tive commercial human demineralized freeze-dried bone allograft makes an effective composite bone inductive implant material. J Periodontol 69:1337–1345

Schwarz F, Bieling K, Latz T, Nuesry E, Becker J (2006a) Healing of intrabony peri-implantitis defects following application of a nanocrystalline hydroxyapatite (Ostim) or a bovine-derived xenograft (Bio-Oss) in combination with a collagen membrane (Bio-Gide). A case series. J Clin Periodontol 33:491–499

Schwarz F, Stratul SI, Herten M, Beck B, Becker J, Sculean A (2006b) Effect of an oily calcium hydroxide suspension (Osteoinductal) on healing of intrabony periodontal defects. A pilot study in dogs. Clin Oral Investig 10:29–34

Schwarz F, Herten M, Ferrari D et al (2007) Guided bone regen-eration at dehiscence-type defects: using biphasic hydroxy-apatite + beta tricalcium phosphate (Bone Ceramic) or a collagen-coated natural bone mineral (BioOss Collagen): an immunohistochemical study in dogs. Int J Oral Maxillofac Surg 36:1198–1206


Schwarz F, Sculean A, Bieling K, Ferrari D, Rothamel D, Becker J (2008) Two-year clinical results following treatment of peri-implantitis lesions using a nanocrystalline hydroxyapa-tite or a natural bone mineral in combination with a collagen membrane. J Clin Periodontol 35:80–87

Schwarz F, Sahm N, Bieling K, Becker J (2009) Surgical regen-erative treatment of peri-implantitis lesions using a nano-crystalline hydroxyapatite or a natural bone mineral in combination with a collagen membrane: a four-year clinical follow-up report. J Clin Periodontol 36:807–814

Sculean A, Barbé G, Chiantella GC, Arweiler NB, Berakdar M, Brecx M (2002a) Clinical evaluation of an enamel matrix protein derivative combined with a bioactive glass for the treatment of intrabony periodontal defects in humans. J Periodontol 73:401–408

Sculean A, Chiantella GC, Windisch P, Gera I, Reich E (2002b) Clinical evaluation of an enamel matrix protein derivative (Emdogain) combined with a bovine-derived xenograft (Bio-Oss) for the treatment of intrabony peri-odontal defects in humans. Int J Periodontics Restorative Dent 22:259–267

Sculean A, Berakdar M, Chiantella GC, Donos N, Arweiler NB, Brecx M (2003) Healing of intrabony defects following treat-ment with a bovine-derived xenograft and collagen membrane. A controlled clinical study. J Clin Periodontol 30:73–80

Sculean A, Stavropoulos A, Windisch P, Keglevich T, Karring T, Gera I (2004a) Healing of human intrabony defects follow-ing regenerative periodontal therapy with a bovine-derived xenograft and guided tissue regeneration. Clin Oral Investig 8:70–74

Sculean A, Windisch P, Chiantella GC (2004b) Human histo-logic evaluation of an intrabony defect treated with enamel matrix derivative, xenograft, and GTR. Int J Periodontics Restorative Dent 24:326–333

Sculean A, Chiantella GC, Windisch P, Arweiler NB, Brecx M, Gera I (2005a) Healing of intra-bony defects following treat-ment with a composite bovine-derived xenograft (Bio-Oss Collagen) in combination with a collagen membrane (Bio-Gide PERIO). J Clin Periodontol 32:720–724

Sculean A, Pietruska M, Schwarz F, Willershausen B, Arweiler NB, Auschill TM (2005b) Healing of human intrabony defects following regenerative periodontal therapy with an enamel matrix protein derivative alone or combined with a bioactive glass. A controlled clinical study. J Clin Periodontol 32:111–117

Sculean A, Windisch P, Keglevich T, Gera I (2005c) Clinical and histologic evaluation of an enamel matrix protein derivative combined with a bioactive glass for the treatment of intra-bony periodontal defects in humans. Int J Periodontics Restorative Dent 25:139–147

Sculean A, Pietruska M, Arweiler NB, Auschill TM, Nemcovsky C (2007a) Four-year results of a prospective-controlled clinical study evaluating healing of intra-bony defects following treat-ment with an enamel matrix protein derivative alone or com-bined with a bioactive glass. J Clin Periodontol 34:507–513

Sculean A, Schwarz F, Chiantella GC, Donos N, Arweiler NB, Brecx M, Becker J (2007b) Five-year results of a prospec-tive, randomized, controlled study evaluating treatment of intra-bony defects with a natural bone mineral and GTR. J Clin Periodontol 34:72–77

Sculean A, Windisch P, Szendröi-Kiss D, Horváth A, Rosta P, Becker J, Gera I, Schwarz F (2008) Clinical and histologic evaluation of an enamel matrix derivative combined with a biphasic calcium phosphate for the treatment of human intrabony periodontal defects. J Periodontol 79:1991–1999

Sepe WW, Bowers GM, Lawrence JJ, Friedlaender GE, Koch RW (1978) Clinical evaluation of freeze-dried bone allografts in periodontal osseous defects–part II. J Periodontol 49:9–14

Serre CM, Papillard M, Chavassieux P, Boivin G (1993) In vitro induction of a calcifying matrix by biomaterials constituted of collagen and/or hydroxyapatite: an ultrastructural comparison of three types of biomaterials. Biomaterials 14:97–106

Setya AB, Bissada NF (1999) Clinical evaluation of the use of calcium sulfate in regenerative periodontal surgery for the treatment of Class III furcation involvement. Periodontal Clin Investig 21:5–14

Shaffer CD, App GR (1971) The use of plaster of paris in treat-ing infrabony periodontal defects in humans. J Periodontol 42:685–690

Shahmiri S, Singh IJ, Stahl SS (1992) Clinical response to the use of the HTR polymer implant in human intrabony lesions. Int J Periodontics Restorative Dent 12:295–299

Shapoff CA, Alexander DC, Clark AE (1997) Clinical use of a bioactive glass particulate in the treatment of human osseous defects. Compend Contin Educ Dent 18:352–358

Shi K, Hayashida K, Hashimoto J, Sugamoto K, Kawai H, Yoshikawa H (2006) Hydroxyapatite augmentation for bone atrophy in total ankle replacement in rheumatoid arthritis. J Foot Ankle Surg 45(5):316–321

Shi H, Ma J, Zhao N, Chen Y, Liao Y (2008) Periodontal regen-eration in experimentally-induced alveolar bone dehiscence by an improved porous biphasic calcium phosphate ceramic in beagle dogs. J Mater Sci Mater Med 19:3515–3524

Shirakata Y, Oda S, Kinoshita A, Kikuchi S, Tsuchioka H, Ishikawa I (2002) Histocompatible healing of periodontal defects after application of an injectable calcium phosphate bone cement. A preliminary study in dogs. J Periodontol 73:1043–1053

Shirakata Y, Yoshimoto T, Goto H, Yonamine Y, Kadomatsu H, Miyamoto M, Nakamura T et al (2007) Favorable periodon-tal healing of 1-wall infrabony defects after application of calcium phosphate cement wall alone or in combination with enamel matrix derivative: a pilot study with canine mandi-bles. J Periodontol 78:889–898

Shirakata Y, Setoguchi T, Machigashira M, Matsuyama T, Furuichi Y, Hasegawa K, Yoshimoto T, Izumi Y (2008) Comparison of injectable calcium phosphate bone cement grafting and open flap debridement in periodontal intrabony defects: a randomized clinical trial. J Periodontol 79:25–32

Shirakata Y, Taniyama K, Yoshimoto T, Miyamoto M, Takeuchi N, Matsuyama T, Noguchi K (2010) Regenerative effect of basic fibroblast growth factor on periodontal healing in two-wall intrabony defects in dogs. J Clin Periodontol 37(4): 374–381

Shirmohammadi A, Chitsazi MT, Lafzi A (2009) A clinical com-parison of autogenous bone graft with and without autoge-nous periodontal ligament graft in the treatment of periodontal intrabony defects. Clin Oral Investig 13:279–286

Sibilla P, Sereni A, Aguiari G, Banzi M, Manzati E, Mischiati C, Trombelli L, del Senno L (2006) Effects of a hydroxyapatite-

141References

based biomaterial on gene expression in osteoblast-like cells. J Dent Res 85:354–358

Simonpietri-C JJ, Novaes AB Jr, Batista EL Jr, Filho EJ (2000) Guided tissue regeneration associated with bovine-derived anorganic bone in mandibular class II furcation defects. 6-month results at re-entry. J Periodontol 71:904–911

Skoglund A, Hising P, Young CA (1997) Clinical and histologic examination of the osseous response to implanted natural bone mineral. Int J Oral Maxillofac Implants 12:194–199

Smith IO, Baumann MJ, McCabe LR (2004) Electrostatic inter-actions as a predictor for osteoblast attachment to biomateri-als. J Biomed Mater Res A 70:436–441

Snyder AJ, Levin MP, Cutright DE (1984) Alloplastic implants of tricalcium phosphate ceramic in human periodontal osseous defects. J Periodontol 55:273–277

Sogal A, Tofe AJ (1999) Risk assessment of bovine spongi-form encephalopathy transmission through bone graft mate-rial derived from bovine bone used for dental applications. J Periodontol 70:1053–1063

Sorensen RG, Wikesjö UM, Kinoshita A, Wozney JM (2004) Periodontal repair in dogs: evaluation of a bioresorbable cal-cium phosphate cement (Ceredex) as a carrier for rhBMP-2. J Clin Periodontol 31:796–804

Sottosanti JS (1993) Aesthetic extractions with calcium sulfate and the principles of guided tissue regeneration. Pract Periodontics Aesthet Dent 5:61–69

Sottosanti JS (1995) Calcium sulfate-aided bone regeneration: a case report. Periodontal Clin Investig 17:10–15

Stahl SS, Froum S (1986) Histological evaluation of human intraosseous healing responses to the placement of trical-cium phosphate ceramic implants. I. Three to eight months. J Periodontol 57:211–217

Stahl SS, Froum SJ (1987) Histologic and clinical responses to porous hydroxylapatite implants in human periodon-tal defects. Three to twelve months postimplantation. J Periodontol 58:689–695

Stahl SS, Froum SJ, Tarnow D (1990) Human clinical and histo-logic responses to the placement of HTR polymer particles in 11 intrabony lesions. J Periodontol 61:269–274

Stanley HR, Hall MB, Colaizzi F, Clark AE (1987) Residual alveolar ridge maintenance with a new endosseous implant material. J Prosthet Dent 58:607–613

Stanley HR, Clark AE, Pameijer CH, Louw NP (2001) Pulp cap-ping with a modified bioglass formula (#A68-modified). Am J Dent 14:227–232

Stavropoulos A, Karring T (2005) Five-year results of guided tissue regeneration in combination with deproteinized bovine bone (Bio-Oss) in the treatment of intrabony periodontal defects: a case series report. Clin Oral Investig 9:271–277

Stavropoulos A, Kostopoulos L, Nyengaard JR, Karring T (2003) Deproteinized bovine bone (Bio-Oss®) and bioactive glass (Biogran®) arrest bone formation when used as an adjunct to guided tissue regeneration (GTR). J Clin Periodontol 30:636–643

Stavropoulos A, Sculean A, Karring T (2004) GTR treatment of intrabony defects with PLA/PGA copolymer or collagen bioresorbable membranes in combination with deproteinized bovine bone (Bio-Oss). Clin Oral Investig 8:226–232

Stavropoulos A, Geenen C, Nyengaard JR, Karring T, Sculean A (2007) Oily calcium hydroxide suspension (Osteoinductal)

used as an adjunct to guided bone regeneration: an experi-mental study in rats. Clin Oral Implants Res 18:761–767

Stavropoulos A, Windisch P, Szendröi-Kiss D, Peter R, Gera I, Sculean A (2010) Clinical and histologic evaluation of gran-ular beta-tricalcium phosphate for the treatment of human intrabony periodontal defects: a report on five cases. J Periodontol 81(2):325–334

Stein JM, Fickl S, Yekta SS, Hoischen U, Ocklenburg C, Smeets R (2009) Clinical evaluation of a biphasic calcium compos-ite grafting material in the treatment of human periodontal intrabony defects: a 12-month randomized controlled clini-cal trial. J Periodontol 80:1774–1782

Stoor P, Söderling E, Salonen JI (1998) Antibacterial effects of a bioactive glass paste on oral microorganisms. Acta Odontol Scand 56:161–165

Stratul SI (2003) Oily calcium hydroxide plus a-TCP in treating intrabony defects. J Clin Periodontol 30:71

Stratul SI, Sculean A (2004) Oily calcium hydroxide suspension and a-TCP in treating intrabony defects. Int Poster J Dent Oral Med 6:Poster 235

Stratul SI, Schwarz F, Becker J, Willershausen B, Sculean A (2006) Healing of intrabony defects following treatment with an oily calcium hydroxide suspension (Osteoinductal). A controlled clinical study. Clin Oral Investig 10:55–60

Strub JR, Gaberthuel TW, Firestone AR (1979) Comparison of tricalcium phosphate and frozen allogenic bone implants in man. J Periodontol 50:624–629

Sugawara A, Fujikawa K, Takagi S, Chow LC (2008) Histological analysis of calcium phosphate bone grafts for surgically created periodontal bone defects in dogs. Dent Mater J 27:787–794

Sukumar S, Drízhal I (2008) Bone grafts in periodontal therapy. Acta Medica (Hradec Kralove) 51:203–207

Sun W, Chu C, Wang J, Zhao H (2007) Comparison of periodon-tal ligament cells responses to dense and nanophase hydroxy-apatite. J Mater Sci Mater Med 18:677–683

Tadic D, Epple M (2004) A thorough physicochemical char-acterisation of 14 calcium phosphate-based bone substitu-tion materials in comparison to natural bone. Biomaterials 25:987–994

Tadjoedin ES, de Lange GL, Bronckers AL, Lyaruu DM, Burger EH (2003) Deproteinized cancellous bovine bone (Bio-Oss) as bone substitute for sinus floor elevation. A retrospective, histomorphometrical study of five cases. J Clin Periodontol 30:261–270

Tamimi F, Torres J, Bettini R, Ruggera F, Rueda C, López-Ponce M, Lopez-Cabarcos E (2008) Doxycycline sustained release from brushite cements for the treatment of periodontal dis-eases. J Biomed Mater Res A 85:707–714

Taschieri S, Del Fabbro M, Testori T, Weinstein R (2007) Efficacy of xenogeneic bone grafting with guided tissue regeneration in the management of bone defects after surgi-cal endodontics. J Oral Maxillofac Surg 65:1121–1127

TenHuisen KS, Brown PW (1998) Formation of calcium-defi-cient hydroxyapatite from alpha-tricalcium phosphate. Biomaterials 19:2209–2217

Tezulas E, Dilek OC (2008) Decontamination of autogenous bone grafts collected from dental implant sites via osteot-omy: a review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106:679–684


Tezulas E, Dilek OC, Topcuoglu N, Kulekci G (2009) Decontamination of autogenous bone grafts collected during dental implant site preparation: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107(5):656–660

Thorwarth M, Schultze-Mosgau S, Kessler P, Wiltfang J, Schlegel KA (2005) Bone regeneration in osseous defects using a resorbable nanoparticular hydroxyapatite. J Oral Maxillofac Surg 63:1626–1633

Thorwarth M, Schlegel KA, Wehhan F, Srour S, Schultze-Mosgau S (2006) Acceleration of de novo bone formation following application of autogenous bone to particulated anorganic bovine material in vivo. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 101:309–316

Throndson RR, Sexton SB (2002) Grafting mandibular third molar extraction sites: a comparison of bioactive glass to a nongrafted site. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94:413–419

Tonetti MS, Pini Prato G, Cortellini P (1995) Effect of cigarette smoking on periodontal healing following GTR in infrabony defects: a preliminary retrospective study. J Clin Periodontol 22:229–234

Tonetti M, Pini-Prato G, Cortellini P (1996) Factors affecting the healing response of intrabony defects following guided tis-sue regeneration and access flap surgery. J Clin Periodontol 23:548–556

Tonetti M, Cortellini P, Suvan J et al (1998) Generalizability of the added benefits of guided tissue regeneration in the treat-ment of deep intrabony defects. Evaluation in a multi-center randomized controlled clinical trial. J Periodontol 69:1183–1192

Tonetti MS, Cortellini P, Lang NP, Suvan JE, Adriaens P, Dubravec D, Fonzar A, Fourmousis I, Rasperini G, Rossi R, Silvestri M, Topoll H, Wallkamm B, Zybutz M (2004) Clinical outcomes following treatment of human intrabony defects with GTR/bone replacement material or access flap alone. A multicenter randomized controlled clinical trial. J Clin Periodontol 31:770–776

Trejo PM, Weltman R, Caffesse R (2000) Treatment of intraosseous defects with bioabsorbable barriers alone or in combination with decalcified freeze-dried bone allograft: a randomized clinical trial. J Periodontol 71:1852–1861

Trombelli L, Heitz-Mayfield LJ, Needleman I, Moles D, Scabbia A (2002) A systematic review of graft materials and biologi-cal agents for periodontal intraosseous defects. J Clin Periodontol 29:117–135

Trombelli L (2005) Which reconstructive procedures are effec-tive for treating the periodontal intraosseous defect? Periodontol 2000 37:88–105

Trombelli L, Annunziata M, Belardo S, Farina R, Scabbia A, Guida L (2006) Autogenous bone graft in conjunction with enamel matrix derivative in the treatment of deep periodon-tal intra-osseous defects: a report of 13 consecutively treated patients. J Clin Periodontol 33:69–75

Trombelli L, Farina R, Franceschetti G, Calura G (2009) Single-flap approach with buccal access in periodontal reconstruc-tive procedures. J Periodontol 80:353–360

Trombelli L, Simonelli A, Pramstraller M, Wikesjö UM, Farina R (2010) Single flap approach with and without guided tissue regeneration and a hydroxyapatite biomaterial in the man-agement of intraosseous periodontal defects. J Periodontol 81:1256–1263

Turner TM, Urban RM, Hall DJ, Andersson GB (2007) Bone ingrowth through porous titanium granulate around a femo-ral stem: histological assessment in a six-month canine hemiarthroplasty model. Ups J Med Sci 112:191–197

Valentini P, Abensur D (1997) Maxillary sinus floor elevation for implant placement with demineralized freeze-dried bone and bovine bone (Bio-Oss): a clinical study of 20 patients. Int J Periodontics Restorative Dent 17:232–241

Valentini P, Abensur DJ (2003) Maxillary sinus grafting with anorganic bovine bone: a clinical report of long-term results. Int J Oral Maxillofac Implants 18:556–560

Valentini P, Abensur D, Densari D, Graziani JN, Hämmerle C (1998) Histological evaluation of Bio-Oss in a 2-stage sinus floor elevation and implantation procedure. A human case report. Clin Oral Implants Res 9:59–64

Valentini P, Abensur D, Wenz B, Peetz M, Schenk R (2000) Sinus grafting with porous bone mineral (Bio-Oss) for implant placement: a 5-year study on 15 patients. Int J Periodontics Restorative Dent 20:245–253

Velasquez-Plata D, Scheyer ET, Mellonig JT (2002) Clinical comparison of an enamel matrix derivative used alone or in combination with a bovine-derived xenograft for the treat-ment of periodontal osseous defects in humans. J Periodontol 73:433–440

Venezia E, Goldstein M, Boyan BD, Schwartz Z (2004) The use of enamel matrix derivative in the treatment of periodontal defects: a literature review and meta-analysis. Crit Rev Oral Biol Med 15:382–402

Villaça JH, Novaes AB Jr, Souza SL, Taba M Jr, Molina GO, Carvalho TL (2005) Bioactive glass efficacy in the periodon-tal healing of intrabony defects in monkeys. Braz Dent J 16(1):67–74

von Arx T, Cochran DL, Hermann JS, Schenk RK, Buser D (2001) Lateral ridgementation using different bone fillers and barrier membrane application. A histologic and histo-morphometric pilot study in the canine mandible. Clin Oral Implants Res 12:260–269

Vouros I, Aristodimou E, Konstantinidis A (2004) Guided tissue regeneration in intrabony periodontal defects following treatment with two bioabsorbable membranes in combina-tion with bovine bone mineral graft. A clinical and radio-graphic study. J Clin Periodontol 31:908–917

Vrouwenvelder WCA, Groot CG, Groot K (1993) Histological and biochemical evaluation of osteoblasts cultured on bioac-tive glass, hydroxylapatite, titanium alloy, and stainless steel. J Biomed Mater Res 27:465–475

Wada T, Wu CH, Sugita H, Sugita N, Katagiri S, Shimizu M, Hara K (1989) Autogenous, allogenic, and beta-TCP grafts: comparative effectiveness in experimental bone furcation defects in dogs. J Oral Implantol 15:231–236

Wagner JR (1989) Clinical and histological case study using resorbable hydroxylapatite for the repair of osseous defects prior to endosseous implant surgery. J Oral Implantol 15: 186–192

Wallace SS, Froum SJ (2003) Effect of maxillary sinusmenta-tion on the survival of endosseous dental implants. A sys-tematic review. Ann Periodontol 8:328–343

Wang HL, Kimble K, Eber R (2002) Use of bone grafts for the enhancement of a GTR-based root coverage procedure: a pilot case study. Int J Periodontics Restorative Dent 22: 119–127

143References

Wang L, Shi H, Chen Y, Xue J, Chen Y, Liao Y (2010) Healing of acute alveolar bone dehiscence following treatment with porous biphasic calcium phosphate in beagle dogs. Clin Oral Investig [Epub ahead of print]

Wenz B, Oesch B, Horst M (2001) Analysis of the risk of transmitting bovine spongiform encephalopathy through bone grafts derived from bovine bone. Biomaterials 22: 1599–1606

Wikesjö UM, Sorensen RG, Kinoshita A, Wozney JM (2002) RhBMP-2/alphaBSM induces significant vertical alveolar ridgementation and dental implant osseointegration. Clin Implant Dent Relat Res 4:174–182

Wikesjö UM, Lim WH, Razi SS, Sigurdsson TJ, Lee MB, Tatakis DN, Hardwick WR (2003) Periodontal repair in dogs: a bioabsorbable calcium carbonate coral implant enhances space provision for alveolar bone regeneration in conjunction with guided tissue regeneration. J Periodontol 74:957–964

Wildemann B, Kadow-Romacker A, Pruss A, Haas NP, Schmidmaier G (2007) Quantification of growth factors in allogenic bone grafts extracted with three different methods. Cell Tissue Bank 8:107–114

Wilson J, Low SB (1992) Bioactive ceramics for periodontal treatment: comparative studies in the Patus monkey. J Appl Biomater 3:123–129

Wilson TG, Glover ME, Schoen J, Baust C, Jacobs T (1984) Compliance with maintenance therapy in a private periodon-tal practice. J Periodontol 55:468–473

Wilson J, Clark AE, Hall M, Hench LL (1993a) Tissue response to bioglass endosseous ridge maintenance implants. J Oral Implantol 19:295–302

Wilson TG, Hale S, Temple R (1993b) The results of efforts to improve compliance with supportive periodontal treatment in a private practice. J Periodontol 64:311–314

Winn SR, Hollinger JO (2000) An osteogenic cell culture sys-tem to evaluate the cytocompatibility of Osteoset, a calcium sulfate bone void filler. Biomaterials 21:2413–2425

Wohlfahrt JC, Aass AM, Rønold HJ, Karlsson S, Ellingsen JE, Saxegaard E, Lyngstadaas SP (2010a) Porous titanium gran-ules in the surgical treatment of peri-implant osseous defects – a randomized clinical trial. Presented at the 19th Annual Scientic Meeting of the European Association for Osseointegration, October 6–9, 2010, Glasgow, United Kingdom. Clin Oral Implants Res 21:1014

Wohlfahrt JC, Monjo M, Rønold HJ, Aass AM, Ellingsen JE, Lyngstadaas SP (2010b) Porous titanium granules promote bone healing and growth in rabbit tibia peri-implant osseous defects. Clin Oral Implants Res 21:165–173

Wohlfahrt JC, Rønold HJ, Aass AM, Heijl L, Lyngstadaas SP (2010c) Porous titanium granules in furcation defects – an animal experimental study. Presented at the 88th General Session of the International Association of Dental Research, July 14–17, 2010, Barcelona, Spain. J Dent Res 89(Spec Iss B):3862

Wong MY, Hong CY, Chang WK (1989) Comparison of histo-logical effects of different bioceramic implants on surgically created periodontal defects in monkeys. Taiwan Yi Xue Hui Za Zhi 88:152–158

Xu HH, Quinn JB, Takagi S, Chow LC (2002) Processing and properties of strong and non-rigid calcium phosphate cement. J Dent Res 81:219–224

Xu HH, Takagi S, Sun L, Hussain L, Chow LC, Guthrie WF, Yen JH (2006) Development of a nonrigid, durable calcium phosphate cement for use in periodontal bone repair. J Am Dent Assoc 137:1131–1138

Xu HH, Carey LE, Simon CG Jr, Takagi S, Chow LC (2007) Premixed calcium phosphate cements: synthesis, physical properties, and cell cytotoxicity. Dent Mater 23:433–441

Xynos ID, Edgar AJ, Buttery LD, Hench LL, Polak JM (2000a) Ionic products of bioactive glass dissolution increase prolif-eration of human osteoblasts and induce insulin like growth factor II mRNA expression and protein synthesis. Biochem Biophys Res Commun 276:461–565

Xynos ID, Hukkanen MV, Batten JJ, Buttery LD, Hench LL, Polak JM (2000b) Bioglass 45 S5 stimulates osteoblast turn-over and enhances bone formation in vitro: implication and applications for bone tissue engineering. Calcif Tissue Int 67: 321–329

Yagihashi K, Miyazawa K, Togari K, Goto S (2009) Demi-neralized dentin matrix acts as a scaffold for repair of articu-lar cartilage defects. Calcif Tissue Int 84:210–220

Yamada M, Minamikawa H, Ueno T, Sakurai K, Ogawa T (2010) N-acetyl cysteine improves affinity of beta-tricalcium phos-phate granules for cultured osteoblast-like cells. J Biomater Appl; (Epub ahead of print)

Yassibag-Berkman Z, Tuncer O, Subasioglu T, Kantarci A (2007) Combined use of platelet-rich plasma and bone grafting with or without guided tissue regeneration in the treatment of anterior interproximal defects. J Periodontol 78:801–809

Yilmaz S, Cakar G, Yildirim B, Sculean A (2010) Healing of two and three wall intrabony periodontal defects following treatment with an enamel matrix derivative combined with autogenous bone. J Clin Periodontol 37:544–550

Yli-Urpo H, Närhi T, Söderling E (2003) Antimicrobial effects of glass ionomer cements containing bioactive glass (S53P4) on oral micro-organisms in vitro. Acta Odontol Scand 61:241–246

Ymane S, Higuchi Y, Abe N, Fujii K, Okamura K, Nosaka T, Funabashi K, Ueno T (1998) Application of denta root tips as bone replacemant material. Nihon Koukuugeka Implant 11:16–22

Yu D, Wong J, Matsuda Y, Fox JL, Higuchi WI, Otsuka M (1992) Self-setting hydroxyapatite cement: a novel skeletal drugde-livery system for antibiotics. J Pharm Sci 81:529–531

Yuan H, Kurashina K, de Bruijn JD, Li Y, de Groot K, Zhang X (1999) A preliminary study on osteoinduction of two kinds of calcium phosphate ceramics. Biomaterials 20: 1799–1806

Yuan H, Li Y, de Bruijin JD, de Groot K, Zhang X (2000) Tissue responses of calcium phosphate cement: a study in dogs. Biomaterials 21:1283–1290

Yuan H, De Groot K (2004) Calcium phosphate biomaterials: an overview. In: Reis RL, Weiner S (eds) Learning from nature how to design new implantable biomaterials. Kluwer Academic Publishers, Dordrecht, pp 37–57

Yukna RA (1990) HTR polymer grafts in human periodontal osseous defects. I. 6-month clinical results. J Periodontol 61:633–642

Yukna RA (1994a) Clinical evaluation of coralline calcium car-bonate as a bone replacement graft material in human peri-odontal osseous defects. J Periodontol 65:177–185


Yukna RA (1994b) Clinical evaluation of HTR polymer bone replacement grafts in human mandibular class II molar fur-cations. J Periodontol 65:342–349

Yukna RA, Greer RO Jr (1992) Human gingival tissue response to HTR polymer. J Biomed Mater Res 26:517–527

Yukna RA, Vastardis S (2005) Comparative evaluation of decal-cified and non-decalcified freeze-dried bone allografts in rhe-sus monkeys. I. Histologic findings. J Periodontol 76:57–65

Yukna RA, Yukna CN (1997) Six-year clinical evaluation of HTR synthetic bone grafts in human grade II molar furca-tions. J Periodontal Res 32:627–633

Yukna RA, Callan DP, Krauser JT, Evans GH, Aichelmann-Reidy ME, Moore K, Cruz R, Scott JB (1998) Multi-center clinical evaluation of combination anorganic bovine-derived hydroxyapatite matrix (ABM)⁄cell binding peptide (P-15) as a bone replacement graft material in human periodontal osseous defects: 6-month results. J Periodontol 69:655–663

Yukna RA, Evans GH, Aichelmann-Reidy MB, Mayer ET (2001) Clinical comparison of bioactive glass bone replace-ment graft material and expanded polytetrafluoroethylene barrier membrane in treating human mandibular molar class II furcations. J Periodontol 72:125–133

Yukna R, Salinas TJ, Carr RF (2002a) Periodontal regeneration following use of ABM/P-15: a case report. Int J Periodontics Restorative Dent 22:146–155

Yukna RA, Krauser JT, Callan DP, Evans GH, Cruz R, Martin M (2002b) Thirty-six month follow-up of 25 patients treated with combination anorganic bovine-derived hydroxyapatite matrix (ABM)/cell-binding peptide (P-15) bone replacement grafts in

human infrabony defects. I. Clinical findings. J Periodontol 73:123–128

Zafiropoulos GG, Hoffmann O, Kasaj A, Willershausen B, Weiss O, Van Dyke TE (2007) Treatment of intrabony defects using guided tissue regeneration and autogenous spongiosa alone or combined with hydroxyapatite/beta-tricalcium phosphate bone substitute or bovine-derived xenograft. J Periodontol 78:2216–2225

Zamet JS, Darbar UR, Griffiths GS, Bulman JS, Brägger U, Bürgin W, Newman HN (1997) Particulate bioglass as a grafting material in the treatment of periodontal intrabony defects. J Clin Periodontol 24:410–418

Zaner DJ, Yukna RA (1984) Particle size of periodontal bone grafting materials. J Periodontol 55:406–409

Zehnder M, Söderling E, Salonen J, Waltimo T (2004) Preliminary evaluation of bioactive glass S53P4 as an endo-dontic medication in vitro. J Endod 30:220–224

Zitzmann NU, Naef R, Schärer P (1997) Resorbable versus non-resorbable membranes in combination with Bio-Oss for guided bone regeneration. Int J Oral Maxillofac Implants 12:844–852

Zitzmann NU, Schärer P, Marinello CP, Schüpbach P, Berglundh T (2001) Alveolar ridgementation with Bio-Oss: a histologic study in humans. Int J Periodontics Restorative Dent 21:288–295

Zucchelli G, Amore C, Montebugnoli L, De Sanctis M (2003) Enamel matrix proteins and bovine porous bone mineral in the treatment of intrabony defects: a comparative controlled clinical trial. J Periodontol 74:1725–1735

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